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Great Plains Medicare Advantage Gold (HMO I-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Great Plains Medicare Advantage Gold (HMO I-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Great Plains Medicare Advantage Gold (HMO I-SNP) in 2025, please refer to our full plan details page.
Great Plains Medicare Advantage Gold (HMO I-SNP) is a HMO I-SNP plan offered by Sanford Health available for enrollment in 2025 to people living in Nebraska (partial). This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Great Plains Medicare Advantage Gold (HMO I-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Great Plains Medicare Advantage Gold (HMO I-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 Great Plains Medicare Advantage Gold (HMO I-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 Great Plains Medicare Advantage Gold (HMO I-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $77.00. 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 $2150.00 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 Great Plains Medicare Advantage Gold (HMO I-SNP) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay different copays depending on the drug tier and pharmacy you use. For example, standard generics have a $45 copay, preferred brands have a $95 copay, and non-preferred drugs have 33% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered Part D drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. If you qualify for the low-income subsidy (LIS), you may be able to receive help with your prescription drug costs.
Additional Benefits
The Great Plains Medicare Advantage Gold (HMO I-SNP) plan offers coverage for inpatient and outpatient services, including mental health and substance abuse treatment. The plan has varying copays for different services, such as $185 for inpatient hospital stays (days 1-5), $50 for outpatient services, and $30 for primary care visits. The plan also covers hearing and vision services, including hearing exams with a $30 copay, and eye exams with a $30 copay. This plan provides additional benefits, including dental services with a 20% coinsurance, and home health services with no copay. It also covers ambulance services, with a $150 copay for ground transport, and emergency services with a $90 copay. However, some services like preventive services, and other services are not covered by this plan.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric, are covered under the Great Plains Medicare Advantage Gold (HMO I-SNP) plan. For days 1-5, the copay is $185, and for days 6-90, there is no copay.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, and ambulatory surgical center services. Outpatient hospital services have a $50 copay, observation services have a $100 copay, and ambulatory surgical center services have a $50 copay, while outpatient substance abuse services include individual and group sessions with a $30 copay. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Great Plains Medicare Advantage Gold (HMO I-SNP) plan, with a $30 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including both ground and air ambulance services. Ground ambulance services have a $150 copay, and air ambulance services have 20% coinsurance; transportation services to a plan-approved health-related location are covered for up to 32 one-way trips per year.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Great Plains Medicare Advantage Gold (HMO I-SNP) plan. Emergency Services have a $90 copay with no coinsurance, while Urgently Needed Services have a $30 copay with no coinsurance; however, Worldwide Emergency Services, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are not covered.
Primary Care See details
The Great Plains Medicare Advantage Gold (HMO I-SNP) plan covers primary care physician services, chiropractic services with a $20 copay for routine care, occupational therapy, physician specialist services with a $30 copay, mental health specialty services with a $30 copay for individual and group sessions, podiatry services with 0-20% coinsurance for routine foot care up to 6 visits per year, other health care professional services with a $30 copay, psychiatric services with a $30 copay for individual and group sessions, physical therapy and speech-language pathology services with no copay or coinsurance, additional telehealth benefits with a $0-$30 copay, and opioid treatment program services.
Preventive Services See details
Preventive services are covered, but annual physical exams, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, fitness benefits, enhanced disease management, telemonitoring services, remote access technologies, home and bathroom safety devices and modifications, and counseling services are not covered. Glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit are covered.
Hearing Services See details
Hearing services with the Great Plains Medicare Advantage Gold (HMO I-SNP) plan include hearing exams with a $30 copay, as well as routine hearing exams and fitting/evaluation for hearing aids with no cost. Prescription hearing aids are covered up to $2,000 per year, but inner ear, outer ear, and over-the-ear hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision Services include coverage for eye exams with a $30 copay, and eyewear. Eyeglass lenses and eyeglass frames are not covered. Contact lenses are covered, up to $100 per year for one pair, and eyeglasses (lenses and frames) are covered with a maximum benefit of $275 per year for one pair.
Dental Services See details
The Great Plains Medicare Advantage Gold (HMO I-SNP) plan covers dental services, including Medicare dental services with a 20% coinsurance. Other dental services include oral exams (2 visits per year), dental x-rays (1 every 5 years), prophylaxis/cleaning (2 visits per year), restorative services, endodontics, periodontics, maxillofacial prosthetics, prosthodontics (removable, 1 visit every 2 years, with a $1,500 limit), and prosthodontics (fixed, 1 visit every 2 years). However, fluoride treatment, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, with coinsurance between 0% and 20%. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Great Plains Medicare Advantage Gold (HMO I-SNP) plan. The coinsurance for dialysis services is 20%.
Medical Equipment See details
The Great Plains Medicare Advantage Gold (HMO I-SNP) plan covers medical equipment, including durable medical equipment (DME), with a 20% coinsurance, and Prosthetics/Medical Supplies with a 20% coinsurance. Diabetic equipment is covered with a coinsurance of 20% for diabetic supplies and diabetic therapeutic shoes/inserts. Durable medical equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including diagnostic procedures and tests, are covered, but lab services are not covered. Diagnostic procedures and tests have no copay, but have a coinsurance of at least 20%. Diagnostic Radiological Services and Therapeutic Radiological Services have a copay of $50, while Outpatient X-Ray Services have a $10 copay.
Home Health Services See details
Home Health Services are covered by the Great Plains Medicare Advantage Gold (HMO I-SNP) plan with no copay and no coinsurance, but prior authorization is required. Additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Great Plains Medicare Advantage Gold (HMO I-SNP) plan, but the services are not covered. There is a copay, but the exact amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Great Plains Medicare Advantage Gold (HMO I-SNP) plan. There is no copay for days 1-20, and a $100 copay for days 21-100.
Other Services See details
Other Services are not covered by the Great Plains Medicare Advantage Gold (HMO I-SNP) plan, including acupuncture, over-the-counter items, meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and more. This plan does not require authorization or referrals for these services.
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