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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 2025, 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. The overall rating for this plan is not yet available for 2025.
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 has a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay varying copays depending on the drug tier and pharmacy. For example, you'll pay no copay for preferred generic drugs at standard or mail order pharmacies, and $40 for standard generic drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs. If you qualify for the low-income subsidy (LIS), your Part D costs will be $0.
Additional Benefits
The Gold Heart & Diabetes (HMO-POS C-SNP) plan offers a comprehensive suite of benefits with varying cost-sharing arrangements. The plan covers inpatient hospital stays with a copay, outpatient services with copays or coinsurance, and partial hospitalization with a copay. Emergency, primary care, preventive, hearing, vision, dental, and home health services are also included, often with copays or no copays, depending on the service. This plan also provides coverage for ambulance and transportation, dialysis, medical equipment, and various diagnostic and radiological services, each with specific cost-sharing requirements. Additionally, the plan covers skilled nursing facility stays, acupuncture treatments, and offers over-the-counter (OTC) items and meal benefits. Benefits are subject to prior authorization in some cases.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with a copay of $150 for days 1-5 and no copay for days 6-90. Additional days for Inpatient Hospital-Acute, Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services includes coverage for all outpatient hospital services, with a copay between $0 and $125, observation services with a $150 copay, and Ambulatory Surgical Center (ASC) services with no copay. Outpatient Substance Abuse services have a copay of $25 for individual sessions and $15 for group sessions, and Outpatient Blood Services have a 20% coinsurance.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization. You will pay a $80 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Gold Heart & Diabetes (HMO-POS C-SNP) plan. Ground ambulance services have a $200 copay, while air ambulance services have a 20% coinsurance. Transportation Services to any health-related location are covered for up to 24 one-way trips per year.
Emergency Services See details
Emergency Services are covered, with a $90 copay. Urgently Needed Services are covered with a $10 copay. Worldwide Emergency Services, including Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are covered, each with a $120 copay, and a maximum plan benefit coverage of $75,000.
Primary Care See details
The Gold Heart & Diabetes (HMO-POS C-SNP) plan covers primary care physician services, chiropractic services with a $10 copay, occupational therapy services with a $10 copay, physician specialist services with a $0-$10 copay, mental health specialty services with a $10-$25 copay, podiatry services with a $10 copay, other health care professional services with a $10 copay, psychiatric services with a $10-$25 copay, physical therapy and speech-language pathology services with a $15 copay, additional telehealth benefits with a $15 copay, and opioid treatment program services with a $25 copay. Routine Chiropractic Care is limited to 12 visits per year.
Preventive Services See details
The Gold Heart & Diabetes (HMO-POS C-SNP) plan covers preventive services, including health education, in-home safety assessments, personal emergency response systems, post-discharge in-home medication reconciliation, re-admission prevention, therapeutic massage, fitness benefits, telemonitoring services, remote access technologies, home and bathroom safety devices and modifications, kidney disease education services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit. However, medical nutrition therapy, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, adult day health services, nutritional/dietary benefits, home-based palliative care, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, and counseling services are not covered.
Hearing Services See details
Hearing Services include routine hearing exams and fitting/evaluation for hearing aids, with no copay, and prescription hearing aids (all types) are covered, but Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, and Prescription Hearing Aids - Over the Ear are not covered, and OTC hearing aids are not covered. Hearing exams have a maximum benefit of $1,000 every three months.
Vision Services See details
Vision Services are covered, including routine eye exams, eyewear, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. There is a maximum plan benefit coverage of $1000 every three months for eye exams.
Dental Services See details
The Gold Heart & Diabetes (HMO-POS C-SNP) plan covers a range of dental services, including oral exams, dental x-rays, and cleanings, with a maximum plan benefit of $1000 every three months. Orthodontic services, restorative services, and other dental services are also covered.
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, while 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 by the Gold Heart & Diabetes (HMO-POS C-SNP) plan. You will pay a coinsurance of 20% for these services.
Medical Equipment See details
Medical equipment, including durable medical equipment, prosthetics, and medical supplies, is covered. Durable Medical Equipment (DME) has a 20% coinsurance with no copay, while Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, but Diagnostic Procedures/Tests, Lab Services, and Outpatient X-Ray Services are not covered. Diagnostic Radiological Services have a copay of at most $50, and Therapeutic Radiological Services have a coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered by the Gold Heart & Diabetes (HMO-POS C-SNP) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Gold Heart & Diabetes (HMO-POS C-SNP) plan, but the specific services of Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services are not covered. There is a copay for covered services, but the specific amount is not detailed in this summary.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, there is no copay, a $150 copay for days 21-36, and no copay for days 37-100.
Other Services See details
The "Gold Heart & Diabetes (HMO-POS C-SNP)" plan covers acupuncture with a $10 copay for up to 12 treatments per year. Over-the-counter (OTC) items and meal benefits for chronic illness are also covered. However, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and other services are not covered.
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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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