A non-government entity
MediGold
Plan ID: H3668-19-1
Plan Summary PageMount Carmel MediGold No Premium (HMO)
2027 Mount Carmel MediGold No Premium (HMO) H3668 — 019 — 1 is a Medicare Advantage plan with drug coverage. It has received a 3.5-out-of-5 star rating from CMS for 2027.
Learn more about Mount Carmel MediGold No Premium (HMO) H3668 - 019 - 1, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.
3.5 / 5 stars for 2027
$0.00 /mo
Monthly premium
$275.00
Drug deductible
$5900.00
Out-of-pocket maximum (In-Network)
Enroll online
Call to enroll
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Get personalized help from a licensed insurance agent
1-877-649-2073 / TTY 711. Call-center hours (ET): Mon-Fri 8am-10pm; Sat 9am-8pm; Sun closed.
Plan Overview
2027 Mount Carmel MediGold No Premium (HMO) H3668 — 019 — 1 is a HMO offered in Central and Southwest Ohio by Mount Carmel Health Plan, Inc.. It has a monthly premium of $0.00.
Premium Breakdown
Monthly plan premium
$0.00
Standard Part B premium (estimated)
$209.50
Note:
CMS has not yet announced the official 2027 standard Medicare Part B premium. The estimated 2027 premium is $209.50, per the 2026 Medicare Trustees Report; we'll update this page when CMS publishes the final amount. Your actual Part B premium may differ based on income (IRMAA), late enrollment penalties, Medicaid assistance, disability status, or other factors. Most people enrolled in Medicare Part B are required to pay this premium.
Special needs plan type
No
Out-of-pocket maximum (In-Network)
$5900.00
Plan Organization:
Mount Carmel Health Plan, Inc.
Parent Company:
Trinity Health Corporation
Plan Type:
HMO
Location:
Central and Southwest Ohio
Drugs Covered:
Yes
Drug Formulary:
Pharmacies:
Doctors Link:
Deductibles
The amount you must pay each year before your plan starts to pay for covered services or drugs.
Drug deductible
$275
Note:
This plan does not charge an annual deductible for all drugs. The $275.00 annual deductible only applies to drugs in certain tiers.
Sign up for Mount Carmel MediGold No Premium (HMO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. Call-center hours (ET): Mon-Fri 8am-10pm; Sat 9am-8pm; Sun closed.
Drug Coverage
Mount Carmel MediGold No Premium (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Benefit Type
Enhanced Alternative
Prescription drug deductible
$275.00
Part D Premium Reduction
This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.
Part D | LIS Full |
|---|---|
$0.00 | $0.00 |
Initial Coverage Phase
After you meet any applicable drug deductible ($275.00 for this plan), you pay the plan's cost sharing until your out-of-pocket costs for covered Part D drugs, including certain payments made on your behalf, reach $2,400 in 2027. You then enter catastrophic coverage and pay nothing for covered Part D drugs for the rest of the calendar year.
Tier | Preferred Pharmacy | Standard Pharmacy | Preferred Mail | Standard Mail |
|---|---|---|---|---|
1. Preferred Generic | - | $0.00 copay | - | $0.00 copay |
2. Generic | - | $5.00 copay | - | $0.00 copay |
3. Preferred Brand | - | 25% coinsurance | - | 25% coinsurance |
4. Non-Preferred Drug | - | 40% coinsurance | - | 40% coinsurance |
5. Specialty Tier | - | 30% coinsurance | - | 30% coinsurance |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,400, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
Mount Carmel MediGold No Premium (HMO) also provides the following benefits.
Inpatient Hospital
Inpatient Hospital benefits are covered.
Inpatient Hospital-Acute
Inpatient Hospital-Acute benefits are covered.
| Days 1-5: | Days 6-90: | |
|---|---|---|
| Copayment | 385.00 | 0.00 |
More Details:
Copayment for Medicare-covered stay
0.00
Additional Days for Inpatient Hospital-Acute
Not covered.
Non-Medicare-covered Stay for Inpatient Hospital-Acute
Not covered.
Upgrades for Inpatient Hospital-Acute
Not covered.
Inpatient Hospital Psychiatric
Inpatient Hospital Psychiatric benefits are covered.
| Days 1-5: | Days 6-90: | |
|---|---|---|
| Copayment | 385.00 | 0.00 |
More Details:
Copayment for Medicare-covered stay
0.00
Additional Days for Inpatient Hospital Psychiatric
Not covered.
Non-Medicare-covered Stay for Inpatient Hospital Psychiatric
Not covered.
Outpatient Services
Outpatient Services benefits are covered.
All Outpatient Hospital Services
All Outpatient Hospital Services benefits are covered.
Outpatient Hospital Services
Outpatient Hospital Services benefits are covered.
Cost Sharing:
Observation Services
Observation Services benefits are covered.
Cost Sharing:
Ambulatory Surgical Center (ASC) Services
Ambulatory Surgical Center (ASC) Services benefits are covered.
Cost Sharing:
Outpatient Substance Abuse Services
Not covered.
Individual Sessions for Outpatient Substance Abuse
Individual Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum copayment
35.00
Maximum copayment
35.00
Group Sessions for Outpatient Substance Abuse
Group Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum copayment
35.00
Maximum copayment
35.00
Outpatient Blood Services
Outpatient Blood Services benefits are covered.
Cost Sharing:
Partial Hospitalization
Partial Hospitalization benefits are covered.
Partial Hospitalization
Partial Hospitalization benefits are covered.
Cost Sharing:
Partial Hospitalization
Partial Hospitalization benefits are covered.
Cost Sharing:
Ambulance and Transportation Services
Ambulance and Transportation Services benefits are covered.
All Ambulance Services
All Ambulance Services benefits are covered.
Ground Ambulance Services
Ground Ambulance Services benefits are covered.
Cost Sharing:
Air Ambulance Services
Air Ambulance Services benefits are covered.
Cost Sharing:
Transportation Services
Transportation Services benefits are covered.
Cost Sharing:
Transportation Services - Plan Approved Health-related Location
Transportation Services - Plan Approved Health-related Location benefits are covered.
More Details:
Description
Excluding Stretcher rides, other modes include any special transport requirements for medically fragile or physically/mentally challenged members, based on the members medical needs documentation. Other modes of transportation include ambulance, wheelchair, and extra-large wheelchair vehicles.
Transportation Services - Any Health-related Location
Not covered.
Emergency Services
Emergency Services benefits are covered.
Emergency Services
Emergency Services benefits are covered.
Cost Sharing:
More Details:
Enter number of days or hours
48
Urgently Needed Services
Urgently Needed Services benefits are covered.
Cost Sharing:
Worldwide Emergency Services
Not covered.
Worldwide Emergency Coverage
Worldwide Emergency Coverage benefits are covered.
Cost Sharing:
Worldwide Urgent Coverage
Worldwide Urgent Coverage benefits are covered.
Cost Sharing:
Worldwide Emergency Transportation
Worldwide Emergency Transportation benefits are covered.
Cost Sharing:
Primary Care
Primary Care benefits are covered.
Primary Care Physician Services
Primary Care Physician Services benefits are covered.
Cost Sharing:
Chiropractic Services
Chiropractic Services benefits are covered.
Cost Sharing:
Routine Chiropractic Care
Not covered.
Occupational Therapy Services
Occupational Therapy Services benefits are covered.
Cost Sharing:
Physician Specialist Services
Physician Specialist Services benefits are covered.
Cost Sharing:
Mental Health Specialty Services
Not covered.
Individual Sessions for Mental Health Specialty Services
Individual Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum copayment
35.00
Maximum copayment
35.00
Group Sessions for Mental Health Specialty Services
Group Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum copayment
35.00
Maximum copayment
35.00
Podiatry Services
Podiatry Services benefits are covered.
More Details:
Minimum copayment
35.00
Maximum copayment
35.00
Other Health Care Professional
Other Health Care Professional benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
35.00
Psychiatric Services
Not covered.
Individual Sessions for Psychiatric Services
Individual Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum copayment
35.00
Maximum copayment
35.00
Group Sessions for Psychiatric Services
Group Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum copayment
35.00
Maximum copayment
35.00
Physical Therapy and Speech-Language Pathology Services
Physical Therapy and Speech-Language Pathology Services benefits are covered.
Cost Sharing:
Additional Telehealth Benefits
Additional Telehealth Benefits benefits are covered.
Cost Sharing:
Opioid Treatment Program Services
Opioid Treatment Program Services benefits are covered.
More Details:
Minimum copayment
35.00
Maximum copayment
35.00
Preventive Services
Preventive Services benefits are covered.
Medicare-covered Zero Dollar Preventive Services
Medicare-covered Zero Dollar Preventive Services benefits are covered.
Annual Physical Exam
Annual Physical Exam benefits are covered.
Cost Sharing:
Additional Preventive Services
Not covered.
Health Education
Not covered.
In-Home Safety Assessment
Not covered.
Personal Emergency Response System (PERS)
Not covered.
Medical Nutrition Therapy (MNT)
Not covered.
Post discharge In-Home Medication Reconciliation
Not covered.
Re-admission Prevention
Not covered.
Wigs for Hair Loss Related to Chemotherapy
Not covered.
Weight Management Programs
Not covered.
Alternative Therapies
Not covered.
Therapeutic Massage
Not covered.
Adult Day Health Services
Not covered.
Nutritional/Dietary Benefit
Not covered.
Home-Based Palliative Care
Not covered.
In-Home Support Services
Not covered.
Support for Caregivers of Enrollees
Not covered.
Additional Sessions of Smoking and Tobacco Cessation Counseling
Not covered.
Fitness Benefit
Fitness Benefit benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Enhanced Disease Management
Not covered.
Telemonitoring Services
Not covered.
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline) benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Minimum copayment
0.00
Maximum copayment
0.00
Home and Bathroom Safety Devices and Modifications
Not covered.
Counseling Services
Not covered.
Kidney Disease Education Services
Kidney Disease Education Services benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Other Preventive Services
Other Preventive Services benefits are covered.
Glaucoma Screening
Glaucoma Screening benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Diabetes Self-Management Training
Diabetes Self-Management Training benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Digital Rectal Exams
Digital Rectal Exams benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
EKG following Welcome Visit
EKG following Welcome Visit benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Hearing Services
Hearing Services benefits are covered.
Hearing Exams
Hearing Exams benefits are covered.
Cost Sharing:
Routine Hearing Exams
Routine Hearing Exams benefits are covered.
More Details:
Number of visits
1
Minimum copayment
0.00
Maximum copayment
0.00
Fitting/Evaluation for Hearing Aid
Fitting/Evaluation for Hearing Aid benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Prescription Hearing Aids
Not covered.
Prescription Hearing Aids (all types)
Prescription Hearing Aids (all types) benefits are covered.
More Details:
Quantity for Hearing Aids
2
Minimum copayment
599.00
Maximum copayment
899.00
Prescription Hearing Aids - Inner Ear
Not covered.
Prescription Hearing Aids - Outer Ear
Not covered.
Prescription Hearing Aids - Over the Ear
Not covered.
OTC Hearing Aids
Not covered.
Vision Services
Vision Services benefits are covered.
Eye Exams
Eye Exams benefits are covered.
Cost Sharing:
Routine Eye Exams
Routine Eye Exams benefits are covered.
Cost Sharing:
More Details:
Number of visits
1
Eyewear
Eyewear benefits are covered.
Cost Sharing:
More Details:
Combined maximum amount
250.00
Contact Lenses
Contact Lenses benefits are covered.
Cost Sharing:
Eyeglasses (lenses and frames)
Eyeglasses (lenses and frames) benefits are covered.
Cost Sharing:
Eyeglass lenses
Eyeglass lenses benefits are covered.
Cost Sharing:
Eyeglass frames
Eyeglass frames benefits are covered.
Cost Sharing:
Upgrades
Not covered.
Dental Services
Dental Services benefits are covered.
Medicare Dental Services
Medicare Dental Services benefits are covered.
Cost Sharing:
Other Dental Services
Other Dental Services benefits are covered.
Cost Sharing:
More Details:
Maximum amount
1000.00
Oral Exams
Oral Exams benefits are covered.
More Details:
Number of visits
2
Dental X-Rays
Dental X-Rays benefits are covered.
More Details:
Number of X-Rays
1
Description
X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.
Other Diagnostic Dental Services
Other Diagnostic Dental Services benefits are covered.
More Details:
Number of visits
1
Description
Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.
Prophylaxis (Cleaning)
Prophylaxis (Cleaning) benefits are covered.
More Details:
Number of visits
2
Fluoride Treatment
Fluoride Treatment benefits are covered.
More Details:
Number of visits
2
Other Preventive Dental Services
Other Preventive Dental Services benefits are covered.
More Details:
Number of visits
1
Description
Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.
Orthodontic Services
Not covered.
Restorative Services
Restorative Services benefits are covered.
Cost Sharing:
More Details:
Number of visits
1
Description
Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.
Coinsurance percentage
50
Adjunctive General Services
Adjunctive General Services benefits are covered.
Cost Sharing:
More Details:
Number of visits
1
Description
Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.
Endodontics
Endodontics benefits are covered.
Cost Sharing:
More Details:
Number of visits
1
Description
Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.
Coinsurance percentage
70
Periodontics
Periodontics benefits are covered.
Cost Sharing:
More Details:
Number of visits
1
Description
Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.
Coinsurance percentage
70
Prosthodontics, removable
Not covered.
Maxillofacial Prosthetics
Not covered.
Implant Services
Not covered.
Prosthodontics, fixed
Not covered.
Oral and Maxillofacial Surgery
Oral and Maxillofacial Surgery benefits are covered.
Cost Sharing:
More Details:
Number of visits
1
Description
Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.
Coinsurance percentage
50
Orthodontics
Not covered.
Home Infusion bundled Services
Not covered.
Dialysis Services
Dialysis Services benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Medical Equipment
Medical Equipment benefits are covered.
Durable Medical Equipment (DME)
Durable Medical Equipment (DME) benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Prosthetics/Medical Supplies - Non-Medicare benefit
Not covered.
Prosthetic Devices
Prosthetic Devices benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Medical Supplies
Medical Supplies benefits are covered.
Cost Sharing:
Diabetic Equipment
Not covered.
Diabetic Supplies
Diabetic Supplies benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Diabetic Therapeutic Shoes/Inserts
Diabetic Therapeutic Shoes/Inserts benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Diabetic Equipment
Diabetic Equipment benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Diagnostic and Radiological Services
Diagnostic and Radiological Services benefits are covered.
All Diagnostic services
Not covered.
Diagnostic Procedures/Tests
Diagnostic Procedures/Tests benefits are covered.
More Details:
Minimum copayment
50.00
Maximum copayment
50.00
Lab Services
Lab Services benefits are covered.
Cost Sharing:
All Radiological Services
Not covered.
Diagnostic Radiological Services
Diagnostic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum copayment
415.00
Therapeutic Radiological Services
Therapeutic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Outpatient X-Ray Services
Outpatient X-Ray Services benefits are covered.
Cost Sharing:
Home Health Services
Home Health Services benefits are covered.
Cost Sharing:
Cardiac Rehabilitation Services
Not covered.
Skilled Nursing Facility (SNF)
Skilled Nursing Facility (SNF) benefits are covered.
| Days 1-20: | Days 21-65: | Days 66-100: | |
|---|---|---|---|
| Copayment | 0.00 | 221.00 | 0.00 |
Additional Days beyond Medicare-covered for Skilled Nursing Facility (SNF)
Not covered.
Other Services
Other Services benefits are covered.
Acupuncture
Acupuncture benefits are covered.
Cost Sharing:
More Details:
Limit for Number of Treatments
6
Over-the-Counter (OTC) Items
Over-the-Counter (OTC) Items benefits are covered.
Cost Sharing:
More Details:
Maximum plan benefit coverage amount
45.00
Attestation
The Nicotine Replacement Therapy (NRT) being offered does not duplicate any Part D OTC or formulary drugs.
Meal Benefit
Meal Benefit benefits are covered.
Cost Sharing:
Dual Eligible SNPs with Highly Integrated Services
Not covered.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. Call-center hours (ET): Mon-Fri 8am-10pm; Sat 9am-8pm; Sun closed.
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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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