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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: CH, CO, GH, and NV. 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 $2750.00 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 an enhanced alternative drug benefit. The plan has no deductible. During the initial coverage phase, you will pay a $0 copay for preferred generic drugs and specialty tier drugs at standard and mail order pharmacies. Standard generic drugs have a $40 copay, and preferred brand drugs have a $100 copay. For non-preferred drugs, you will pay 33% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Gold Heart & Diabetes (HMO-POS C-SNP) plan provides comprehensive coverage with a variety of benefits. Inpatient hospital stays have a copay, while outpatient services have varying copays, and certain services like hearing, vision, and dental have coverage up to a set amount. The plan also offers coverage for emergency services, primary care, preventive services, and home health services. The cost for these services varies, with some having copays and others having coinsurance.
Inpatient Hospital See details
Inpatient hospital services, including acute and psychiatric care, are covered by the Gold Heart & Diabetes (HMO-POS C-SNP) plan. For days 1-7 of inpatient hospital stays, there is a $150 copay, with no copay for days 8-90, and additional days and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay of $0-$125, observation services with a $150 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services include individual sessions with a $25 copay and group sessions with a $15 copay. Outpatient blood services are covered with 20% coinsurance.
Partial Hospitalization See details
Partial Hospitalization is covered and requires prior authorization, with a copay of $80.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under 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 not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $90 copay, Urgently Needed Services have a $15 copay, and Worldwide Emergency Services have a $120 copay for Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation.
Primary Care See details
The Gold Heart & Diabetes (HMO-POS C-SNP) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy with a $15 copay, physician specialist services with a $0-$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 $15 copay, psychiatric services with a $25 copay for individual sessions and a $10 copay for group sessions, 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 an annual physical exam, 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 screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. Medical Nutrition Therapy (MNT), wigs for hair loss, 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 under the Gold Heart & Diabetes (HMO-POS C-SNP) plan include routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids (all types). Hearing exams have a maximum benefit of $700 every three months, and there is no copay or coinsurance. Prescription hearing aids do not have a copay or coinsurance, however, prescription hearing aids - inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision Services includes coverage for routine eye exams with a maximum benefit of $700 every three months, and also covers eyewear including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. There is no copay or coinsurance for any of these services.
Dental Services See details
The Gold Heart & Diabetes (HMO-POS C-SNP) plan covers a maximum of $700 for dental services every three months. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis, fluoride treatments, 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 are all covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Gold Heart & Diabetes (HMO-POS C-SNP) plan, and prior authorization is required. For Medicare Part B Insulin Drugs, there is a $35 copay, while other Medicare Part B drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Gold Heart & Diabetes (HMO-POS C-SNP) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered, with 20% coinsurance for Durable Medical Equipment (DME), Medicare-covered Prosthetic Devices, and Medicare-covered Medical Supplies, and no copay. 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. Diagnostic Procedures/Tests, and Lab Services are not covered. Diagnostic Radiological Services have a copay of at most $50.00, while Therapeutic Radiological Services have a coinsurance of at most 20%. Outpatient X-Ray Services are not covered.
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, but the specific services of Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, and Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services are not covered. There is a copay for the covered services, but the exact amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Gold Heart & Diabetes (HMO-POS C-SNP) 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 for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Gold Heart & Diabetes (HMO-POS C-SNP) plan covers acupuncture with a $20 copay for up to 12 treatments per year, and covers over-the-counter items and a meal benefit for chronic illnesses. The plan does not cover dual eligible SNPs with highly integrated services, nor does it cover any additional services like Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and other services.
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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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