Great Plain Medicare Advantage Gold (HMO I-SNP)

South Dakota Institutional Special Needs I-SNP Plan (2025 Plan)


Monthly Premium

Your Cost
$77
by Great Plains Medicare Advantage

Additional Coverage

HearingVisionDental

Overall Government Star Rating

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Plan Name
Great Plain Medicare Advantage Gold (HMO I-SNP)
Insurance Carrier
Great Plains Medicare Advantage
Plan Type
Institutional Special Needs Plan (I-SNP)
Network Type
HMO

Great Plain Medicare Advantage Gold (HMO I-SNP) is a Institutional Special Needs Plan (I-SNP), which is available in South Dakota and offered by the health insurance company Great Plains Medicare Advantage. This plan’s network type is HMO which determines in-network doctors who accept the health plan and whether a referral is needed.

Monthly Premium
$77
Annual Deductible
$0
Max Out-of-Pocket
$2,150
Primary doctor visit
$0 copay
Specialist visit
$30 copay per visit
ER visit
$90 copay per visit (always covered)
Ambulance
$150 copay

Great Plain Medicare Advantage Gold (HMO I-SNP) has a monthly premium cost of $77 per month, with an annual deductible of $0 and a maximum out of pocket cost sharing of $2,150 In-network. The most common benefit costs which people evaluate when choosing a plan are costs for a primary doctor visit, specialist doctor visit, emergency room visit, and ambulance. These costs are listed in this summary section and a full list of benefit costs for Great Plain Medicare Advantage Gold (HMO I-SNP) are defined below.

Yes
Part D Prescription Drug Coverage
Yes
Dental
Yes
Vision
Yes
Hearing

Great Plain Medicare Advantage Gold (HMO I-SNP) is a Medicare Advantage plan which does include Medicare Part D Prescription Drug coverage. Other common benefits included with Medicare Advantage plans are coverage for dental, vision, and hearing. Great Plain Medicare Advantage Gold (HMO I-SNP) includes coverage for hearing, vision, dental.

Medicare Advantage health plans can offer even more additional benefits. Great Plain Medicare Advantage Gold (HMO I-SNP) includes coverage for the following additional benefits:

Other benefits

Fitness benefit
Not covered
Over the counter drug benefits
Not covered
In-home support services
Not covered
Home and bathroom safety devices
Not covered
Meals for short duration
Not covered
Annual physical exams
Not covered
Telehealth
Limited coverage

Monthly Premium
$77
Health Portion of Premium
$57
Drug Portion of Premium
$20
Health Plan Deductible
$0
Health Plan Max Out-of-Pocket
$2,150 In-network
Nationwide Coverage included
No
Hearing Coverage included
Yes
Vision Coverage included
Yes
Dental Coverage included
Yes

Doctor Services

Primary doctor visit
$0 copay
Specialist visit
$30 copay per visit

Tests, labs, & imaging

Diagnostic tests & procedures
20% coinsurance
Lab services
$0 copay
Diagnostic radiology services (like MRI)
$50 copay
Outpatient x-rays
$10 copay
Emergency care
$90 copay per visit (always covered)
Urgent care
$30 copay per visit (always covered)

Hospital Services

Inpatient hospital coverage
$185 per day for days 1 through 5
$0 per day for days 6 through 90
Outpatient hospital coverage
$50 copay per visit

Skilled nursing facility

Skilled nursing facility
$0 per day for days 1 through 20
$100 per day for days 21 through 100

Preventive services

Preventive services
$0 copay

Ambulance

Ground ambulance
$150 copay

Therapy services

Occupational therapy visit
$0 copay
Physical therapy & speech & language therapy visit
$0 copay

Mental health services

Outpatient group therapy with a psychiatrist
$30 copay
Outpatient individual therapy with a psychiatrist
$30 copay
Outpatient group therapy visit
$30 copay
Outpatient individual therapy visit
$30 copay

Opioid treatment services

Opioid treatment services
Covered

Other services

Durable medical equipment (like wheelchairs & oxygen)
20% coinsurance per item
Prosthetics (like braces, artificial limbs)
20% coinsurance per item
Diabetes supplies
20% coinsurance per item

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

TiersInitial coverage phaseCatastrophic coverage phase
Preferred Generic$4.00 copay$0 copay
Generic$10.00 copay$0 copay
Preferred Brand$45.00 copay$0 copay
Non-Preferred Drug$95.00 copay$0 copay
Specialty Tier33% coinsurance$0 copay

Part B Drugs

Chemotherapy drugs
0-20% coinsurance
Other Part B drugs
0-20% coinsurance

Hearing

Hearing exam
$30 copay
Fitting/evaluation
$0 copay
Hearing aids - All types
$0 copay

Preventive Dental

Oral exam
In-network: $0 copay
Out-of-network: $0 copay
Cleaning
In-network: $0 copay
Out-of-network: $0 copay
Fluoride treatment
Not covered
Dental x-rays
In-network: $0 copay
Out-of-network: $0 copay

Comprehensive dental

Restorative services
In-network: $0 copay
Out-of-network: $0 copay
Endodontics
In-network: $0 copay
Out-of-network: $0 copay
Periodontics
In-network: $0 copay
Out-of-network: $0 copay
Prosthodontics, removable
In-network: $0 copay
Out-of-network: $0 copay
Prosthodontics, fixed
In-network: $0 copay
Out-of-network: $0 copay
Maxillofacial prosthetics
In-network: $0 copay
Out-of-network: $0 copay
Implant services
Not covered
Oral and maxillofacial surgery
In-network: $0 copay
Out-of-network: $0 copay
Orthodontics
Not covered
Adjunctive general services
Not covered

Vision

Routine eye exam
$0 copay
Contact lenses
$0 copay
Eyeglasses (frames & lenses)
$0 copay
Eyeglass frames (only)
Not covered
Eyeglass lenses (only)
Not covered
Upgrades
$0 copay

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