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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 Counties: GA, MA, PA, PL, CH, CO, GH, and NV. 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 $55.00. 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 $3400.00 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 a copay for your prescriptions, which varies depending on the drug tier and pharmacy. For example, you'll pay a $5 copay for preferred generic drugs at a standard mail pharmacy, and a $47 copay for standard generic drugs at a standard pharmacy. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for your Part D covered drugs. If you qualify for the low-income subsidy (LIS), you may have reduced premiums.
Additional Benefits
The Gold Advantage (HMO-POS) plan provides coverage for a wide array of services, including inpatient and outpatient hospital care, with varying copays for different services. Emergency, primary care, preventive, hearing, vision, dental, and home health services are included, with many offering no copay or low copays. You will also have coverage for ambulance, and home infusion services, with coinsurance costs for some services, such as dialysis and medical equipment.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you pay a $195 copay for days 1-7, and no copay for days 8-90; for Inpatient Hospital Psychiatric, you pay a $225 copay for days 1-7, and no copay for days 8-90. Additional days for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, Non-Medicare-covered Stay for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, and upgrades for Inpatient Hospital-Acute are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $225, Observation Services with a $195 copay, Ambulatory Surgical Center (ASC) Services with no copay, Individual and Group Sessions for Outpatient Substance Abuse with copays of $25 and $15, respectively, and Outpatient Blood Services with 20% coinsurance.
Partial Hospitalization See details
Partial Hospitalization is covered under the Gold Advantage (HMO-POS) plan, but requires prior authorization. You will pay a copay of $80 for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Gold Advantage (HMO-POS) plan, with a $200 copay for ground ambulance services and 20% coinsurance for air ambulance services. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Gold Advantage (HMO-POS) plan. Emergency Services has a $135 copay, Urgently Needed Services has a $45 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 $15 copay, mental health specialty services with a $25 copay for individual sessions and a $10 copay for group sessions, podiatry services with a $15 copay, other health care professional services with a $20 copay, psychiatric services with a $25 copay for individual sessions and a $25 copay for group sessions, physical therapy and speech-language pathology services with a $35 copay, additional telehealth benefits with a $15 copay, and opioid treatment program services with a $25 copay. Routine chiropractic care is limited to 6 visits per year.
Preventive Services See details
Preventive Services are covered, including Medicare-covered services with no copay. Other covered services include annual physical exams, health education, in-home safety assessments, personal emergency response systems, post-discharge in-home medication reconciliation, re-admission prevention, remote access technologies, in-home support services, therapeutic massage, fitness benefit, 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 a 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.
Hearing Services See details
Hearing Services include routine hearing exams and fitting/evaluation for hearing aids with no copay, and prescription hearing aids are partially covered, while OTC hearing aids are not covered. The plan offers a maximum of $525 every three months for hearing exams. Prescription Hearing Aids (all types) are covered, while Prescription Hearing Aids - Inner Ear, Outer Ear, and Over the Ear are not covered.
Vision Services See details
Vision services, including eye exams and eyewear, are covered by the Gold Advantage (HMO-POS) plan. Routine eye exams are covered with no copay, and eyewear benefits are covered with no copay, with a maximum plan benefit coverage of $525 every three months.
Dental Services See details
Dental services are covered, with a maximum plan benefit of $525.00 every three months. Specific services include 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, all of which are unlimited.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. 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 under the Gold Advantage (HMO-POS) plan. You will pay a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered by the Gold Advantage (HMO-POS) plan, including 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, while Prosthetic Devices and Diabetic Supplies have a 20% coinsurance, and Medical Supplies have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. Diagnostic Procedures/Tests, and Lab Services are not covered, while Diagnostic Radiological Services have a copay of at most $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. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Gold Advantage (HMO-POS) plan. Specifically, 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.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Gold Advantage (HMO-POS) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The Gold Advantage (HMO-POS) plan covers acupuncture with a $15 copay and covers over-the-counter items, up to $50 per month. Other services such as meal benefits, and services like Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services are not covered.
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