Super Plus (HMO C-SNP) H4869 001 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.
Super Plus (HMO C-SNP) H4869-001 is a Chronic Condition SNP (C-SNP). A Chronic Condition SNP is for beneficiaries with the
following severe or disabling chronic conditions: . 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.
The Super Plus (HMO C-SNP) H4869-001 is available to residents to
Medicare eligible seniors in Arizona.
All Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage.
Super Plus (HMO 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 Super Plus (HMO 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 $0 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. Super Plus (HMO 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.
H4869-001 Formulary and Drug Coverage
Super Plus (HMO 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.
The benefit information provided is a summary of what Super Plus (HMO 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.
$0 per day for days 1 through 20 $188 per day for days 21 through 36 $0 per day for days 37 through 100
Occupational therapy visit
Rehabilitation services
$20 copay
Physical therapy and speech and language therapy visit
Rehabilitation services
$20 copay
Cleaning
Preventive dental
$0 copay
Dental x-ray(s)
Preventive dental
$0 copay
Fluoride treatment
Preventive dental
$0 copay
Oral exam
Preventive dental
$0 copay
Preventive care
$0 copay
Outpatient hospital coverage
$0-195 copay per visit
In-Network Other health plan deductibles?
No
Optional supplemental benefits
No
Inpatient hospital - psychiatric
Mental health services
$225 per day for days 1 through 7 $0 per day for days 8 through 90
Outpatient group therapy visit
Mental health services
$10 copay
Outpatient group therapy visit with a psychiatrist
Mental health services
$10 copay
Outpatient individual therapy visit
Mental health services
$25 copay
Outpatient individual therapy visit with a psychiatrist
Mental health services
$25 copay
Chemotherapy
Medicare Part B drugs
20% coinsurance
Other Part B drugs
Medicare Part B drugs
20% coinsurance
Diabetes supplies
Medical equipment/supplies
$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)
Medical equipment/supplies
20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)
Medical equipment/supplies
20% coinsurance per item
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$3,000 In-network
Inpatient hospital coverage
$100 per day for days 1 through 7 $0 per day for days 8 through 90
Fitting/evaluation
Hearing
$0 copay
Hearing aids
Hearing
$0 copay
Hearing exam
Hearing
$0 copay
Health plan deductible
$0
Ground ambulance
$200 copay
Foot exams and treatment
Foot care (podiatry services)
$0 copay
Routine foot care
Foot care (podiatry services)
$0 copay
Emergency
Emergency care/Urgent care
$90 copay per visit (always covered)
Urgent care
Emergency care/Urgent care
$0 copay
Primary
Doctor visits
$0 copay
Specialist
Doctor visits
$0-20 copay per visit
Diagnostic radiology services (e.g., MRI)
Diagnostic procedures/lab services/imaging
$50 copay
Diagnostic tests and procedures
Diagnostic procedures/lab services/imaging
$50 copay
Lab services
Diagnostic procedures/lab services/imaging
$0 copay
Outpatient x-rays
Diagnostic procedures/lab services/imaging
$0 copay
Diagnostic services
Comprehensive dental
$0 copay
Endodontics
Comprehensive dental
$0 copay
Extractions
Comprehensive dental
$0 copay
Non-routine services
Comprehensive dental
$0 copay
Periodontics
Comprehensive dental
$0 copay
Prosthodontics, other oral/maxillofacial surgery, other services
Comprehensive dental
$0 copay
Restorative services
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 Super Plus (HMO C-SNP) requires you to live in that plan’s service area. The service area is listed below:
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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Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.
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