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Dialysis Plus (HMO-POS C-SNP) By Gold Kidney of Arizona



Dialysis Plus (HMO-POS C-SNP) H4869 003 0 is a 2023 Medicare Advantage Special Needs Plan plan by Gold Kidney of Arizona. This plan from Gold Kidney of Arizona works with Medicare to give you significant coverage beyond original Medicare. If you decide to sign up you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Gold Kidney of Arizona and not Original Medicare. All Medicare SNPs also provide Medicare additional Part-D drug coverage. Dialysis Plus (HMO-POS C-SNP) H4869-003 is a Chronic Condition SNP (C-SNP). A Chronic Condition SNP is for beneficiaries with the following severe or disabling chronic conditions: Chronic Lung Disorders. If you have Medicare and you develop certain severe or disabling conditions you can join a Medicare SNP designed to serve people with those conditions at any time.







2023 Medicare Special Needs Plan Details

Plan Name:Dialysis Plus (HMO-POS C-SNP)
Plan ID:H4869 003 0
Special Needs Type:Chronic or Disabling Condition
Provider:Gold Kidney of Arizona
Plan Year:2023
Plan Type:Local HMO
Monthly Premium C+D:$0
Chronic Condition:Chronic Lung Disorders
Part C Premium:
Part D (Drug) Premium:$0
Part D Supplemental Premium$0
Total Part D Premium:$0
Drug Deductible:$0
Tiers with No Deductible:0
Benchmark:not below the regional benchmark
Type of Medicare Health Plan:Enhanced Alternative
Drug Benefit Type:Enhanced
Gap Coverage:Yes
Similar Plan: H4869-004


The Dialysis Plus (HMO-POS C-SNP) H4869-003 is available to residents to Medicare eligible seniors in Arizona. All Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. Dialysis Plus (HMO-POS C-SNP) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you need special care for a physician specialist, your primary care physician will make the arrangements and tell you where you can go in the network. You will need your PCPs okay, called a referral. Without getting a referral or services received from out-of-network providers are not typically covered by the plan.



How much does Dialysis Plus (HMO-POS C-SNP) cost?


Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Gold Kidney of Arizona charges a Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.


Part-D Deductible and Premium

An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. Dialysis Plus (HMO-POS C-SNP) has a monthly drug premium of $0 and a $0 drug deductible. This Gold Kidney of Arizona plan offers a $0 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0. This Premium covers any enhanced plan benefits offered by Gold Kidney of Arizona above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $0. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.


Gold Kidney of Arizona Gap Coverage

In 2023 once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Gold Kidney of Arizona plan does offer additional coverage through the gap.


H4869-003 Formulary and Drug Coverage

Dialysis Plus (HMO-POS C-SNP) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Special Needs Plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.

Drug Tier Copay
Preferred
Pharmacy		 Copay
Nonpreferred
Pharmacy
Tier 1 NA $0
Tier 2 NA $5
Tier 3 NA $45
Tier 4 NA $100
Tier 5 NA 33%
Tier 6 NA $0
The complete Dialysis Plus (HMO-POS C-SNP) H4869-003 Formulary
*Initial Coverage Phase and 30 day supply





2023 Summary of Benefits

The benefit information provided is a summary of what Dialysis Plus (HMO-POS C-SNP) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Gold Kidney of Arizona helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

Wellness programs (e.g., fitness, nursing hotline)Covered


Contact lenses


In-Network Vision$0 copay


Eyeglass frames


In-Network Vision$0 copay


Eyeglass lenses


In-Network Vision$0 copay


Eyeglasses (frames and lenses)


In-Network Vision$0 copay


Other


VisionNot covered


Routine eye exam


In-Network Vision$0 copay


Upgrades


In-Network Vision$0 copay



In-Network Transportation$0 copay
In-Network Skilled Nursing Facility$0 per day for days 1 through 20
$100 per day for days 21 through 47
$0 per day for days 48 through 100
Out-of-Network Skilled Nursing Facility$0 per day for days 1 through 20
$100 per day for days 21 through 47
$0 per day for days 48 through 100


Occupational therapy visit


In-Network Rehabilitation services$20 copay
Out-of-Network Rehabilitation services$20 copay


Physical therapy and speech and language therapy visit


Out-of-Network Rehabilitation services$20 copay
In-Network Rehabilitation services$20 copay


Cleaning


In-Network Preventive dental$0 copay


Dental x-ray(s)


In-Network Preventive dental$0 copay


Fluoride treatment


In-Network Preventive dental$0 copay


Oral exam


In-Network Preventive dental$0 copay



In-Network Preventive care$0 copay
Out-of-Network Preventive care$0 copay
Out-of-Network Outpatient hospital coverage$0-195 copay per visit
In-Network Outpatient hospital coverage$0-195 copay per visit
In-Network Other health plan deductibles?No
Optional supplemental benefitsNo


Inpatient hospital - psychiatric


Out-of-Network Mental health services$225 per day for days 1 through 5
$0 per day for days 6 through 90
In-Network Mental health services$225 per day for days 1 through 5
$0 per day for days 6 through 90


Outpatient group therapy visit


In-Network Mental health services$10 copay
Out-of-Network Mental health services$10-25 copay


Outpatient group therapy visit with a psychiatrist


In-Network Mental health services$10 copay
Out-of-Network Mental health services$10-25 copay


Outpatient individual therapy visit


Out-of-Network Mental health services$10-25 copay
In-Network Mental health services$25 copay


Outpatient individual therapy visit with a psychiatrist


In-Network Mental health services$25 copay
Out-of-Network Mental health services$10-25 copay


Chemotherapy


Out-of-Network Medicare Part B drugs20% coinsurance
In-Network Medicare Part B drugs20% coinsurance


Other Part B drugs


In-Network Medicare Part B drugs20% coinsurance
Out-of-Network Medicare Part B drugs20% coinsurance


Diabetes supplies


In-Network Medical equipment/supplies$0 copay
Out-of-Network Medical equipment/supplies$0 copay


Durable medical equipment (e.g., wheelchairs, oxygen)


Out-of-Network Medical equipment/supplies20% coinsurance per item
In-Network Medical equipment/supplies20% coinsurance per item


Prosthetics (e.g., braces, artificial limbs)


Out-of-Network Medical equipment/supplies20% coinsurance per item
In-Network Medical equipment/supplies20% coinsurance per item



Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$2,700 In-network
In-Network Inpatient hospital coverage$175 per day for days 1 through 7
$0 per day for days 8 through 90
Out-of-Network Inpatient hospital coverage$175 per day for days 1 through 7
$0 per day for days 8 through 90


Fitting/evaluation


In-Network Hearing$0 copay


Hearing aids


In-Network Hearing$0 copay


Hearing exam


In-Network Hearing$0 copay
Out-of-Network Hearing$0 copay



Health plan deductible$0
In-Network Ground ambulance$200 copay
Out-of-Network Ground ambulance$200 copay


Foot exams and treatment


In-Network Foot care (podiatry services)$0 copay
Out-of-Network Foot care (podiatry services)$0 copay


Routine foot care


Foot care (podiatry services)Not covered


Emergency


Emergency care/Urgent care$120 copay per visit (always covered)


Urgent care


Emergency care/Urgent care$40 copay per visit (always covered)


Primary


Out-of-Network Doctor visits$0 copay
In-Network Doctor visits$0 copay


Specialist


Out-of-Network Doctor visits$0-20 copay per visit
In-Network Doctor visits$0-20 copay per visit


Diagnostic radiology services (e.g., MRI)


Out-of-Network Diagnostic procedures/lab services/imaging$50 copay
In-Network Diagnostic procedures/lab services/imaging$50 copay


Diagnostic tests and procedures


In-Network Diagnostic procedures/lab services/imaging20% coinsurance
Out-of-Network Diagnostic procedures/lab services/imaging20% coinsurance


Lab services


Out-of-Network Diagnostic procedures/lab services/imaging$0 copay
In-Network Diagnostic procedures/lab services/imaging$0 copay


Outpatient x-rays


Out-of-Network Diagnostic procedures/lab services/imaging$0 copay
In-Network Diagnostic procedures/lab services/imaging$0 copay


Diagnostic services


In-Network Comprehensive dental$0 copay


Endodontics


In-Network Comprehensive dental$0 copay


Extractions


In-Network Comprehensive dental$0 copay


Non-routine services


In-Network Comprehensive dental$0 copay


Periodontics


In-Network Comprehensive dental$0 copay


Prosthodontics, other oral/maxillofacial surgery, other services


In-Network Comprehensive dental$0 copay


Restorative services


In-Network Comprehensive dental$0 copay



In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?No




Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Special Need Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Dialysis Plus (HMO-POS C-SNP) requires you to live in that plan’s service area. The service area is listed below:

State: Medicare Arizona
County:SNP in Gila

SNP in Maricopa

SNP in Pima

SNP in Pinal





Source: CMS.

Plans as of Oct 1, 2022.

Last updated on

Notes: Data are subject to change. All contracts for 2023 have not been finalized. For 2023, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part Part D benefit.

Includes 2023 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.

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