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Gold Kidney Health Plan

Plan ID: H4869-9-0

Essential Care (HMO-POS)

2024 Essential Care (HMO-POS) H4869 — 009 — 0 is a Medicare Advantage plan .

Learn more about Essential Care (HMO-POS) H4869 - 009 - 0, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.

$0.00 /mo

Monthly premium

Coming soon

Health deductible

$8850.00

Out-of-pocket maximum

Enroll online

Call to enroll

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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!

Overview Benefits & Costs Drug Coverage Additional Benefits

Plan Overview

2024 Essential Care (HMO-POS) H4869 — 009 — 0 is a Local HMO offered in Counties: GA, MA, PA, PL by Gold Kidney Health Plan. It has a monthly premium of $0.00 and includes a Part B premium discount of $100.00.

Premium Breakdown

Standard Part B Premium

$174.70

Part B premium reduction

- $100.00

Monthly Plan Premium

$0.00

Total Premium:

$74.70

Note:

The standard Part B premium for 2024 is $174.70. Your Part B premium may differ based on factors including late enrollment, income, and disability status. Higher-income beneficiaries may pay an income-related monthly adjustment amount (IRMAA). The Part B premium is required to be paid by everyone enrolled in Medicare Part B.

Special needs plan type

Out-of-pocket maximum

$8850.00

Plan Organization:

Gold Kidney Health Plan

Plan Type:

Local HMO

Location:

Counties: GA, MA, PA, PL

Drugs Covered:

Drug Formulary:

Formulary Link

Pharmacies:

Pharmacies Link

Doctor Choice:

Plan Doctors Only (some exceptions)

Doctors Link:

Doctors Link

Deductibles

The amount you must pay each year before your plan starts to pay for covered services or drugs.

Health deductible

Coming soon

Sign up for Essential Care (HMO-POS)

Enroll online

Call to enroll

Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week

Drug Coverage

Essential Care (HMO-POS) does not provide drug coverage. If drug coverage is something you need, you should consider shopping for other plans that do provide cost sharing on drugs.

Additional Benefits

Essential Care (HMO-POS) also provides the following benefits.

Note:

Limits, Authorizations, and Referrals may apply for the benefits below. Contact the plan for details.

Comprehensive dental

Non-routine services

Not covered

Diagnostic services

Not covered

Restorative services

Not covered

Endodontics

Not covered

Periodontics

Not covered

Extractions

Not covered

Prosthodontics, other oral/maxillofacial surgery, other services

Not covered

Preventive dental

Oral exam

Not covered

Cleaning

Not covered

Fluoride treatment

Not covered

Dental x-ray(s)

Not covered

Diagnostic procedures/lab services/imaging

Diagnostic tests and procedures

In-Network: 20% coinsurance

Out-Of-Network: 20% coinsurance

Lab services

In-Network: 20% coinsurance

Out-Of-Network: 20% coinsurance

Diagnostic radiology services (eg, MRI)

In-Network: 20% coinsurance

Out-Of-Network: 20% coinsurance

Outpatient x-rays

In-Network: 20% coinsurance

Out-Of-Network: 20% coinsurance

Doctor visits

Primary

In-Network: 20% coinsurance per visit

Out-Of-Network: 20% coinsurance per visit

Specialist

In-Network: 20% coinsurance per visit

Out-Of-Network: 20% coinsurance per visit

Emergency care/Urgent care

Emergency

20% coinsurance per visit (always covered)

Urgent care

20% coinsurance per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment

In-Network: 20% coinsurance

Out-Of-Network: 20% coinsurance

Routine foot care

Not covered

Ground ambulance

Service

In-Network: 20% coinsurance

Out-Of-Network: 20% coinsurance

Hearing

Hearing exam

In-Network: 20% coinsurance

Out-Of-Network: 20% coinsurance

Fitting/evaluation

Not covered

Hearing aids - inner ear

Not covered

Hearing aids - outer ear

Not covered

Hearing aids - over the ear

Not covered

Inpatient hospital coverage

Service

In-Network: Coming soon

Out-Of-Network: Coming soon

Outpatient hospital coverage

Service

In-Network: 20% coinsurance per visit

Out-Of-Network: 20% coinsurance per visit

Optional benefits

Service

Medical equipment/supplies

Durable medical equipment (eg, wheelchairs, oxygen)

In-Network: 20% coinsurance per item

Out-Of-Network: 20% coinsurance per item

Prosthetics (eg, braces, artificial limbs)

In-Network: 20% coinsurance per item

Out-Of-Network: 20% coinsurance per item

Diabetes supplies

In-Network: 20% coinsurance per item

Out-Of-Network: 20% coinsurance per item

Medicare Part B drugs

Chemotherapy

In-Network: 0-20% coinsurance

Out-Of-Network: $35 copay or 0-20% coinsurance

Other Part B drugs

In-Network: 0-20% coinsurance

Out-Of-Network: $35 copay or 0-20% coinsurance

Part B Insulin drugs

In-Network: $35 copay

Out-Of-Network: $35 copay or 0-20% coinsurance

Mental health services

Inpatient hospital - psychiatric

In-Network: Coming soon

Out-Of-Network: Coming soon

Outpatient group therapy visit with a psychiatrist

In-Network: 20% coinsurance

Out-Of-Network: 20% coinsurance

Outpatient individual therapy visit with a psychiatrist

In-Network: 20% coinsurance

Out-Of-Network: 20% coinsurance

Outpatient group therapy visit

In-Network: 20% coinsurance

Out-Of-Network: 20% coinsurance

Outpatient individual therapy visit

In-Network: 20% coinsurance

Out-Of-Network: 20% coinsurance

Preventive care

Service

In-Network: $0 copay

Out-Of-Network: $0 copay

Rehabilitation services

Occupational therapy visit

In-Network: 20% coinsurance

Out-Of-Network: 20% coinsurance

Physical therapy and speech and language therapy visit

In-Network: 20% coinsurance

Out-Of-Network: 20% coinsurance

Skilled Nursing Facility

Service

In-Network: Coming soon

Out-Of-Network: Coming soon

Transportation

Service

Not covered

Vision

Routine eye exam

Not covered

Other

Not covered

Contact lenses

Not covered

Eyeglasses (frames and lenses)

Not covered

Eyeglass frames

Not covered

Eyeglass lenses

Not covered

Upgrades

Not covered

Wellness programs (eg, fitness, nursing hotline)

Service

Not covered

Plan Providers

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.

Get Personalized Help from a licensed insurance agent

1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week

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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.

* 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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