2027 Medicare Advantage plan

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

Great Plains Medicare Advantage HMO I-SNP Special Needs Plan

CMS plan ID: H7511-003-0 · Plan year: 2027

Great Plains Medicare Advantage (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$24.60
Drug deductible$700.00
In-network medical out-of-pocket maximum$9,850.00
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
$0.00
Part D premium
$24.60
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
Same as Medicare's Part B deductible

Applies to certain in-network Medicare-covered services.

In-network medical maximum
$9,850.00

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

Plan-level deductibles may still apply when a service-specific deductible is listed as No.

Common medical services and member costs
ServiceIn-networkWhat to know
Primary care doctor

$0

Service-specific deductible
No
Specialist visit

20% coinsurance

Service-specific deductible
No
Approval required
No
Referral required
No
Telehealth

0% to 20% coinsurance

Service-specific deductible
No
Approval required
No
Referral required
No
Emergency care

$90.00 copay

Urgent care

20% coinsurance

Home health

$0

Service-specific deductible
No
Approval required
No
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% coinsurance

Service-specific deductible
No
Approval required
No
Referral required
No
Medicare-covered foot care

20% coinsurance

Service-specific deductible
No
Approval required
No
Referral required
No
Other health professionals

20% coinsurance

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.
CareYour share of the costWhat to know
Inpatient hospital stay

Original Medicare cost-sharing rules apply.

Approval required
No
Referral required
No
Benefit period
Original Medicare
Inpatient mental health care

Original Medicare cost-sharing rules apply.

Approval required
No
Referral required
No
Benefit period
Original Medicare
Skilled nursing facility

Original Medicare cost-sharing rules apply.

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
ServiceIn-networkWhat to know
Outpatient hospital care

20% coinsurance

Service-specific deductible
No
Hospital observation services

20% coinsurance

Service-specific deductible
No
Ambulatory surgical center

20% coinsurance

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
ServiceIn-networkWhat 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)

20% coinsurance

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

20% coinsurance

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
ServiceIn-networkWhat 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

20% coinsurance

Service-specific deductible
No
Approval required
No
Referral required
No
Substance use treatment, group sessions

20% coinsurance

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

20% coinsurance

Service-specific deductible
No
Approval required
No
Referral required
No
Mental health, group sessions

20% coinsurance

Service-specific deductible
No
Approval required
No
Referral required
No
Psychiatry, individual sessions

20% coinsurance

Service-specific deductible
No
Approval required
No
Referral required
No
Psychiatry, group sessions

20% coinsurance

Service-specific deductible
No
Approval required
No
Referral required
No

Therapy and rehabilitation

Therapy and rehabilitation and member costs
ServiceIn-networkWhat to know
Occupational therapy

20% coinsurance

Service-specific deductible
No
Approval required
No
Referral required
No
Physical and speech therapy

20% coinsurance

Service-specific deductible
No
Approval required
No
Referral required
No
Cardiac rehabilitation

20% coinsurance

Service-specific deductible
No
Approval required
No
Referral required
No
Intensive cardiac rehabilitation

20% coinsurance

Service-specific deductible
No
Approval required
No
Referral required
No
Pulmonary rehabilitation

20% coinsurance

Service-specific deductible
No
Approval required
No
Referral required
No
Supervised exercise for peripheral artery disease

20% coinsurance

Service-specific deductible
No
Approval required
No
Referral required
No

Ambulance, medical equipment and supplies

Ambulance, medical equipment and supplies and member costs
ServiceIn-networkWhat to know
Ground ambulance

20% coinsurance

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
ServiceIn-networkWhat to know
Medicare-covered dental

20% coinsurance

Vision benefits

Vision benefits and member costs
ServiceIn-networkWhat to know
Medicare-covered eye exams

20% coinsurance

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
ServiceIn-networkWhat to know
Medicare-covered hearing exams

20% coinsurance

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.

This plan uses a non-tiered standard drug benefit; individual drug prices are not listed here.

Available prescription supply lengths, not price quotes
PharmacySupply
Standard retail34 days
Standard retail68 days
Standard retail102 days
Out-of-network pharmacy34 days
Long-term care pharmacy34 days

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

Nebraska