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

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

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Contact lenses

In-Network Vision	$0 copay

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Eyeglass frames

In-Network Vision	$0 copay

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Eyeglass lenses

In-Network Vision	$0 copay

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Eyeglasses (frames and lenses)

In-Network Vision	$0 copay

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Other

Vision	Not covered

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Routine eye exam

In-Network Vision	$0 copay

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Upgrades

In-Network Vision	$0 copay

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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

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Occupational therapy visit

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

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Physical therapy and speech and language therapy visit

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

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Cleaning

In-Network Preventive dental	$0 copay

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Dental x-ray(s)

In-Network Preventive dental	$0 copay

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Fluoride treatment

In-Network Preventive dental	$0 copay

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Oral exam

In-Network Preventive dental	$0 copay

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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 benefits	No

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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

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Outpatient group therapy visit

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

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Outpatient group therapy visit with a psychiatrist

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

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Outpatient individual therapy visit

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

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Outpatient individual therapy visit with a psychiatrist

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

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Chemotherapy

Out-of-Network Medicare Part B drugs	20% coinsurance
In-Network Medicare Part B drugs	20% coinsurance

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Other Part B drugs

In-Network Medicare Part B drugs	20% coinsurance
Out-of-Network Medicare Part B drugs	20% coinsurance

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Diabetes supplies

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

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

Out-of-Network Medical equipment/supplies	20% coinsurance per item
In-Network Medical equipment/supplies	20% coinsurance per item

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

Out-of-Network Medical equipment/supplies	20% coinsurance per item
In-Network Medical equipment/supplies	20% coinsurance per item

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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

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Fitting/evaluation

In-Network Hearing	$0 copay

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Hearing aids

In-Network Hearing	$0 copay

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Hearing exam

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

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

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Foot exams and treatment

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

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Routine foot care

Foot care (podiatry services)	Not covered

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Emergency

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

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Urgent care

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

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Primary

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

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Specialist

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

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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

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Diagnostic tests and procedures

In-Network Diagnostic procedures/lab services/imaging	20% coinsurance
Out-of-Network Diagnostic procedures/lab services/imaging	20% coinsurance

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Lab services

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

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Outpatient x-rays

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

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Diagnostic services

In-Network Comprehensive dental	$0 copay

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Endodontics

In-Network Comprehensive dental	$0 copay

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Extractions

In-Network Comprehensive dental	$0 copay

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Non-routine services

In-Network Comprehensive dental	$0 copay

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Periodontics

In-Network Comprehensive dental	$0 copay

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Prosthodontics, other oral/maxillofacial surgery, other services

In-Network Comprehensive dental	$0 copay

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Restorative services

In-Network Comprehensive dental	$0 copay

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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:

Source: CMS.

Plans as of Oct 1, 2022.

Last updated on December 03, 2022

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.