Great Plain Medicare Advantage Gold (I-SNP) Plan Details for Pennington County, SD
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*This plan is new and has not yet been rated by CMS.
Great Plain Medicare Advantage Gold (I-SNP) is a Institutional Medicare Advantage Special Needs Plan. The 2025 Annual Enrollment period starts October 15. Plan benefits begin January
This private health insurance option offers all of the same basic benefits as Original Medicare, but out-of-pocket costs are different. It may include additional benefits that Medicare Part A and Part B do not cover.
Individuals must meet all Institutional SNP qualification requirements to join this I-SNP plan.
| Plan Basics | |
|---|---|
| Plan ID: | H1787-002-0 |
| Plan Type: | HMO I-SNP |
| Plan Year: | 2025 |
| Premium: | $77.00/mo Plus your Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | 2,150.00 /yr |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | Enhanced $0.00 deductible |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | Pennington County, SD |
| Insured By: | Great Plains Medicare Advantage |
| Summary of Benefits |
|---|
Health Plan Cost Sharing & Benefits
The following table is a summary of the most common out-of-pocket costs you will incur if you join this Great Plains Medicare Advantage plan:
Doctor's Office Visits
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | Not Covered |
| Specialist: | $30 Copay |
Emergency, Urgent, and Inpatient Hospital Coverage
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $90 Copay |
| Urgent care: | $30 Copay |
| Ground ambulance: | $150 Copay |
| Inpatient hospital care: | $185.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
| Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $100.00 per day for days 21 and beyond |
Foot Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Foot Exams and Treatments (Medicare-covered): | 20% Coinsurance |
| Routine Foot Care: | Not Covered |
Chiropractic Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Medicare-covered chiropractic: | $20 Copay |
| Routine chiropractic: | $20 Copay |
Mental Health Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | $30 Copay |
| Outpatient group therapy: | $30 Copay |
| Inpatient psychiatric hospital care: | $185.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Rehabilitation Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | Not Covered |
| Occupational therapy: | Not Covered |
Medical Equipment and Supplies
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | 20% Coinsurance |
| Durable medical equipment: | 20% Coinsurance Prior Authorization Required |
| Prosthetics: | 20% Coinsurance |
Diagnostics, Lab Services, and Imaging
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | $50 Copay Prior Authorization Required |
| Lab services: | Not Covered |
| Outpatient x-rays: | $10 Copay Prior Authorization Required |
| Diagnostic tests and procedures: | 20% Coinsurance Prior Authorization Required |
Medicare Part B Drugs
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered): | 20% Coinsurance |
Dental Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare Covered Preventive Dental | 20% Coinsurance |
| Oral exam | $0 |
| Dental x-rays | $0 |
| Cleaning | $0 |
| Periodontics | Not Covered |
| Endodontics | Not Covered |
| Restorative Services | Not Covered |
Hearing Aids and Services
| Service | Member Cost (in-network) |
|---|---|
| Fitting/evaluation | Covered Limits may apply |
| Hearing aids | Not Covered |
| Hearing exam | Covered Limits may apply |
Vision Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare-covered eye exam (in-network) | $ to $30 Copay |
| Routine eye exam (in-network) | Covered Limits may apply |
| Eyewear benefits | None |
Feel free to download our Great Plain Medicare Advantage Gold Summary of Benefits information.
Prescription Drug Plan Costs & Benefits
Great Plain Medicare Advantage Gold includes an enhanced benefit Medicare Part D plan (PDP). Enhanced plans have a higher actuarial value than basic plans. Actuarial value simply refers to the percentage of cost that's covered by the plan.
Prescription Drug Plan Premium
Although the prescription drug plan (Part D) premium is bundled with the total plan cost, some plans have supplemental costs and/or offer low-income subsidy (LIS) assistance. LIS, also known as Extra Help, is a Social Security program that helps people with limited income and resources lower or cut Part D costs.
The following table outlines the premium details of this prescription drug plan.
| Basic Part D Premium: | $20.30 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $20.30 |
| Low Income Premium Subsidy: | $50.63 |
| Low Income Premium Subsidy CMS Pays: | $20.30 |
| Low Income Subsidy Premium: | $0.00 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $0.00. You must pay this amount at the pharmacy before Great Plains Medicare Advantage begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Great Plain Medicare Advantage Gold has out-of-pocket costs you must pay when you pick up your prescriptions.
| Drug Tier | Retail | Mail Order | |
|---|---|---|---|
| Preferred Generic | $4.00 | N/A | |
| Generic | $10.00 | N/A | |
| Preferred Brand | $45.00 | N/A | |
| Non-Preferred Drug | $95.00 | N/A | |
| Specialty Tier | 33.00% | N/A | |
| Select Care Drugs | $0.00 | N/A | |
| *The Part D deductible does not apply. | |||
CMS Rating Marks
Each year Medicare rates I-SNP plans, using a 5-star rating system, in nine major categories. These ratings are designed to help you understand the quality of care and service you can expect if you qualify and choose to join Great Plain Medicare Advantage Gold .
| CMS Measure | Star Rating |
|---|---|
| 2025 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | Not enough data available |
| Managing Chronic (Long Term) Conditions | Not enough data available |
| Member Experience with Health Plan | Not enough data available |
| Complaints and Changes in Plans Performance | Not enough data available |
| Health Plan Customer Service | Not enough data available |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | Not enough data available |
| Member Experience with the Drug Plan | Not enough data available |
| Drug Safety and Accuracy of Drug Pricing |
Additional I-SNP Plan Options
Here are some additional Medicare SNP plans that might be worth reviewing:
Contact Great Plains Medicare Advantage
| Website: | Great Plains Medicare Advantage Plan Page |
|---|---|
| Providers: | Great Plains Medicare Advantage Providers Page |
| Formulary: | Great Plains Medicare Advantage Formulary Page |
| Pharmacy: | Great Plains Medicare Advantage Pharmacy Page |
| New Member Health Plan Help: | (877)701-0784 |
| New Member Health Plan TTY: | 711 |
| New Member Part D Help: | (877)701-0784 |
| New Member Part D TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Advantage program on www.medicare.gov.
Health Plan Compatibility
Medicare Advantage Special Needs Plans (SNPs) are generally incompatible with most other health insurance options. Enrolling in an SNP plan while having Medicare Part A and/or Medicare Part B will result in disenrollment from Original Medicare. Additionally, it is not possible to simultaneously hold a Medicare Supplement Insurance policy and be part of an SNP plan.
With a D-SNP, members keep the same Medicaid plan and Medicaid benefits. If you are a Veteran and have VA Health Benefits, you may be able to care from your local VA hospital.
Citations & References
- Great Plains Medicare Advantage, http://www.greatplainsmedicareadvantage.com, Last Accessed October 13, 2024
- Medicaid.gov, "Medicaid & CHIP in South Dakota", Last Accessed October 1, 2024
- CMS.gov, Landscape Source Files, Last Accessed October 2, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed October 2, 2024
- CMS.gov, Plan Benefits Package, Last Accessed October 5, 2024
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.