2027 Medicare Advantage plan

Great Plains Medicare Advantage Gold (HMO I-SNP): 2027 benefits and costs

Great Plains Medicare Advantage HMO I-SNP Special Needs Plan

CMS plan ID: H7511-004-0 · Plan year: 2027

Great Plains Medicare Advantage Gold (HMO I-SNP) is a 2027 Medicare Advantage plan offered by Great Plains Medicare Advantage. It is listed in Nebraska.

2027 plan costs at a glance

Monthly plan premium$119.00

Drug deductible$300.00

In-network medical out-of-pocket maximum$3,750.00

Organization: Great Plains Medicare Advantage
Plan organization: GOOD SAMARITAN INSURANCE PLAN OF NEBRASKA, INC.
Parent company: Sanford Health
Plan type: HMO I-SNP
Part C premium: $80.00
Part D premium: $39.00
Prescription drug coverage: Yes
Special Needs Plan type: Institutional
2027 CMS Star Rating: Not enough data available

Standard monthly Medicare Part B premium: $209.50 (estimated)

You must continue to pay your Medicare Part B premium.

In-network medical deductible: None
In-network medical maximum: $3,750.00

Who can join this Special Needs Plan?

This plan has institutional care eligibility requirements. The plan must confirm your qualifying care needs or living situation before you enroll.

Plan eligibility type: Institutional
Institutional plan type: Hybrid Institutional special needs plan (HI-SNP)

2027 benefit summary

Doctor visits and medical care

Common medical services and member costs
Service	In-network	What to know
Primary care doctor	$0 Service-specific deductible No
Specialist visit	$30.00 copay Service-specific deductible No	Approval required No Referral required No
Telehealth	$0.00 to $200.00 copay Service-specific deductible No	Approval required No Referral required No
Emergency care	$90.00 copay
Urgent care	$0.00 to $30.00 copay
Home health	$0 Service-specific deductible No	Approval required Yes Referral required No
Dialysis	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Part B chemotherapy and radiation drugs	0% to 20% coinsurance Deductible applies No	Approval required Yes
Other Part B drugs	0% to 20% coinsurance Deductible applies No	Approval required Yes
Kidney disease education services	$0 Service-specific deductible No	Approval required No Referral required No
Medicare-covered chiropractic	$20.00 copay Service-specific deductible No	Approval required No Referral required No
Medicare-covered foot care	0% to 20% coinsurance Service-specific deductible No	Approval required No Referral required No
Other health professionals	$0.00 to $30.00 copay Service-specific deductible No	Approval required No Referral required No

Hospital, outpatient surgery and observation care

Inpatient stays and skilled nursing care

In-network stays. Charges can depend on the number of days and the benefit period.
Care	Your share of the cost	What to know
Inpatient hospital stay	$0.00 copay per stay Days 1–5: $300.00 copay per day Days 6–90: $0.00 copay per day	Approval required No Referral required No Benefit period Original Medicare
Inpatient mental health care	$0.00 copay per stay Days 1–5: $300.00 copay per day Days 6–90: $0.00 copay per day	Approval required No Referral required No Benefit period Original Medicare
Skilled nursing facility	Days 1–20: $0.00 copay per day Days 21–100: $100.00 copay per day	Approval required No Referral required No Benefit period Original Medicare

See plan documents for out-of-network hospital and skilled nursing costs.

Hospital, outpatient surgery and observation care and member costs
Service	In-network	What to know
Outpatient hospital care	$0.00 to $200.00 copay Service-specific deductible No
Hospital observation services	$0.00 to $200.00 copay Service-specific deductible No
Ambulatory surgical center	$0.00 to $200.00 copay Service-specific deductible No	Approval required Yes Referral required No
Outpatient blood	20% coinsurance Service-specific deductible No	Approval required No Referral required No

Tests, imaging and laboratory services

Tests, imaging and laboratory services and member costs
Service	In-network	What to know
Diagnostic procedures and tests	$0 Service-specific deductible No	Approval required Yes Referral required No
Laboratory services	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Diagnostic radiology (CT, MRI)	$0.00 to $50.00 copay Service-specific deductible No	Approval required Yes Referral required No
Therapeutic radiology	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
X-rays	$10.00 copay Service-specific deductible No	Approval required Yes Referral required No

Mental health and substance use treatment

Mental health and substance use treatment and member costs
Service	In-network	What to know
Partial hospitalization	$0 Service-specific deductible No	Approval required No Referral required No
Intensive outpatient program	$0 Service-specific deductible No	Approval required No Referral required No
Substance use treatment, individual sessions	$30.00 copay Service-specific deductible No	Approval required No Referral required No
Substance use treatment, group sessions	$30.00 copay Service-specific deductible No	Approval required No Referral required No
Opioid treatment program	$0 Service-specific deductible No	Approval required No Referral required No
Mental health, individual sessions	$30.00 copay Service-specific deductible No	Approval required No Referral required No
Mental health, group sessions	$30.00 copay Service-specific deductible No	Approval required No Referral required No
Psychiatry, individual sessions	$30.00 copay Service-specific deductible No	Approval required No Referral required Yes
Psychiatry, group sessions	$30.00 copay Service-specific deductible No	Approval required No Referral required Yes

Therapy and rehabilitation

Therapy and rehabilitation and member costs
Service	In-network	What to know
Occupational therapy	$0 Service-specific deductible No	Approval required No Referral required No
Physical and speech therapy	$0 Service-specific deductible No	Approval required No Referral required No
Cardiac rehabilitation	$30.00 copay Service-specific deductible No	Approval required No Referral required No
Intensive cardiac rehabilitation	$30.00 copay Service-specific deductible No	Approval required No Referral required No
Pulmonary rehabilitation	$20.00 copay Service-specific deductible No	Approval required No Referral required No
Supervised exercise for peripheral artery disease	$20.00 copay Service-specific deductible No	Approval required No Referral required No

Ambulance, medical equipment and supplies

Ambulance, medical equipment and supplies and member costs
Service	In-network	What to know
Ground ambulance	$150.00 copay Service-specific deductible No	Approval required Yes
Air ambulance	20% coinsurance Service-specific deductible No	Approval required Yes
Durable medical equipment	20% coinsurance Service-specific deductible No	Approval required Yes
Prosthetic devices	20% coinsurance Service-specific deductible No	Approval required Yes
Medical supplies	20% coinsurance Service-specific deductible No	Approval required Yes
Diabetic supplies	20% coinsurance Service-specific deductible No	Approval required Yes
Diabetic shoes and inserts	20% coinsurance Service-specific deductible No	Approval required Yes
Diabetic monitors	20% coinsurance Service-specific deductible No	Approval required Yes

Dental benefits

Dental benefits and member costs
Service	In-network	What to know
Medicare-covered dental	$30.00 copay
Oral examsAdditional plan benefit	$0
Dental X-raysAdditional plan benefit	$0
Dental cleaningAdditional plan benefit	$0
FluorideAdditional plan benefit	$0
Restorative dental careAdditional plan benefit	$0
Root canal treatment (endodontics)Additional plan benefit	$0
Gum treatment (periodontics)Additional plan benefit	$0
Removable dentures (prosthodontics)Additional plan benefit	$0
Dental implantsAdditional plan benefit	$0
Fixed dental restorations (prosthodontics)Additional plan benefit	$0
Oral surgeryAdditional plan benefit	$0
Other dental servicesAdditional plan benefit	$0

Vision benefits

Vision benefits and member costs
Service	In-network	What to know
Medicare-covered eye exams	$30.00 copay Service-specific deductible No	Approval required No Referral required No
Routine eye examsAdditional plan benefit	$0	Approval required No Referral required No
Medicare-covered eyewear	$0 Service-specific deductible No	Approval required No Referral required No
Contact lensesAdditional plan benefit	$0	Approval required No Referral required No
Eyeglass lensesAdditional plan benefit	$0	Approval required No Referral required No
Eyeglass framesAdditional plan benefit	$0	Approval required No Referral required No

Hearing benefits

Hearing benefits and member costs
Service	In-network	What to know
Medicare-covered hearing exams	$30.00 copay Service-specific deductible No	Approval required No Referral required No
Routine hearing examsAdditional plan benefit	$0	Approval required No Referral required No
Hearing aid fitting and evaluationAdditional plan benefit	$0	Approval required No Referral required No
Prescription hearing aids (all types)Additional plan benefit	$0 Service-specific deductible No	Approval required No Referral required No

Extra benefits

These benefit details are not listed.

Prescription drug coverage

Costs shown are for initial coverage.

Drug deductible exceptions: Tier 1; Tier 2; Tier 6 are exempt from the deductible.

Standard retail costs

On a small screen, scroll the table sideways to compare all fill lengths.

Standard retail: initial-coverage cost per prescription fill
Drug tier	34 days	68 days	102 days
Tier 1Preferred Generic	$0.00	$0.00	$0.00
Tier 2Generic	$8.00	$16.00	$24.00
Tier 3Preferred Brand	25%	25%	25%
Tier 4Non-Preferred Drug	30%	30%	30%
Tier 5Specialty Tier	30%	Not listed	Not listed
Tier 6Select Care Drugs	$0.00	$0.00	$0.00

Mail-order and other pharmacies

Out-of-network pricing: The standard retail copay or coinsurance applies, but the number of days you can fill is limited. Check the supply lengths below and the plan’s out-of-network rules.

Long-term care pharmacy costs

Long-term care pharmacy: initial-coverage cost per prescription fill
Drug tier	34 days
Tier 1Preferred Generic	$0.00
Tier 2Generic	$8.00
Tier 3Preferred Brand	25%
Tier 4Non-Preferred Drug	30%
Tier 5Specialty Tier	30%
Tier 6Select Care Drugs	$0.00

Out-of-network pharmacy costs

Out-of-network pharmacy: initial-coverage cost per prescription fill
Drug tier	33 days
Tier 1Preferred Generic	$0.00
Tier 2Generic	$8.00
Tier 3Preferred Brand	25%
Tier 4Non-Preferred Drug	30%
Tier 5Specialty Tier	30%
Tier 6Select Care Drugs	$0.00

Drug coverage rules and exceptions

Tier 1: Preferred Generic

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: No
Some longer-fill prescriptions require a one-month first fill: No

Tier 2: Generic

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: No
Some longer-fill prescriptions require a one-month first fill: No

Tier 3: Preferred Brand

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: No
Some longer-fill prescriptions require a one-month first fill: No

Tier 4: Non-Preferred Drug

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: No
Some longer-fill prescriptions require a one-month first fill: No

Tier 5: Specialty Tier

Drugs included in this tier: Part D Drugs Only

Tier 6: Select Care Drugs

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: No
Some longer-fill prescriptions require a one-month first fill: No

Initial-coverage prices also apply to drugs exempt from the deductible: Yes

Special cost protections apply to covered insulin and recommended adult vaccines.

Where this plan is offered

CMS lists this plan in 1 state or territory. Availability can vary by county and ZIP code.

View all locations 56 county listings across 1 state or territory