MediGold No Premium (HMO)

H9827 - 001 - 0
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MediGold No Premium (HMO) is a Medicare Advantage Plan by MediGold.

This page features plan details for 2024 MediGold No Premium (HMO) H9827 – 001 – 0 available in Select Counties in New York.

IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:

Locations

MediGold No Premium (HMO) is offered in the following locations.

Plan Overview

MediGold No Premium (HMO) offers the following coverage and cost-sharing.

Insurer:MediGold
Health Plan Deductible:$0.00
MOOP:$6,200.00
Drugs Covered:Yes

Ready to sign up for MediGold No Premium (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

MediGold No Premium (HMO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$174.70 $0.00 $0.00 $0.00 $174.70
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

MediGold No Premium (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:$0.00
Initial Coverage Limit:$5,030.00
Catastrophic Coverage Limit:$8,000.00
Drug Benefit Type:Enhanced Alternative
Additional Gap Coverage:Yes
Formulary Link: Formulary Link

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$0.00$

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00. Once you reach that amount, you will enter the next coverage phase.

Gap Coverage Phase

Tier Cost
All other tiers (Generic)25%
All other tiers (Brand-name)25%

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

MediGold No Premium (HMO) also provides the following benefits.

Health plan deductible

$0

Other health plan deductibles?

In-network No

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

$6,200 In-network

Optional supplemental benefits

Yes

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

In-network No

Outpatient hospital coverage

$0-295 copay per visit (Authorization is not required.) (Referral is not required.)

Doctor visits

Primary$0 copay (Not applicable.) (Not applicable.)
Specialist$30 copay per visit (Authorization is not required.) (Referral is not required.)

Preventive care

$0 copay (Authorization is not required.) (Referral is not required.)

Emergency care/Urgent care

Emergency$90 copay per visit (always covered) (Not applicable.) (Not applicable.)
Urgent care$30 copay per visit (always covered) (Not applicable.) (Not applicable.)

Diagnostic procedures/lab services/imaging

Diagnostic tests and procedures$30 copay (Authorization is required.) (Referral is not required.)
Lab services$0 copay (Authorization is required.) (Referral is not required.)
Diagnostic radiology services (e.g., MRI)$170 copay (Authorization is not required.) (Referral is not required.)
Outpatient x-rays$0 copay (Authorization is not required.) (Referral is not required.)

Hearing

Hearing exam$30 copay (Authorization is not required.) (Referral is not required.)
Fitting/evaluation$0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.)
Hearing aids$599-899 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)

Preventive dental

Oral exam$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
Cleaning$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
Fluoride treatment$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
Dental x-ray(s)$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)

Comprehensive dental

Non-routine servicesNot covered (There are no limits.) (Not applicable.) (Not applicable.)
Diagnostic services$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
Restorative services50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
Endodontics70% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
Periodontics70% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
Extractions50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
Prosthodontics, other oral/maxillofacial surgery, other servicesNot covered (There are no limits.) (Not applicable.) (Not applicable.)

Vision

Routine eye exam$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
OtherNot covered (There are no limits.) (Not applicable.) (Not applicable.)
Contact lenses$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
Eyeglasses (frames and lenses)$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
Eyeglass frames$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
Eyeglass lenses$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
UpgradesNot covered (Not applicable.) (Not applicable.)

Rehabilitation services

Occupational therapy visit$30 copay (Authorization is not required.) (Referral is not required.)
Physical therapy and speech and language therapy visit$30 copay (Authorization is not required.) (Referral is not required.)

Ground ambulance

$240 copay (Not applicable.) (Not applicable.)

Transportation

Not covered (Not applicable.) (Not applicable.)

Foot care (podiatry services)

Foot exams and treatment$30 copay (Authorization is not required.) (Referral is not required.)
Routine foot careNot covered (Not applicable.) (Not applicable.)

Medical equipment/supplies

Durable medical equipment (e.g., wheelchairs, oxygen)20% coinsurance per item (Authorization is required.) (Not applicable.)
Prosthetics (e.g., braces, artificial limbs)20% coinsurance per item (Authorization is required.) (Not applicable.)
Diabetes supplies$0 copay per item (Authorization is required.) (Not applicable.)

Wellness programs (e.g., fitness, nursing hotline)

Covered (Authorization is not required.) (Referral is not required.)

Medicare Part B drugs

Chemotherapy0-20% coinsurance (Authorization is required.) (Not applicable.)
Other Part B drugs0-20% coinsurance (Authorization is required.) (Not applicable.)
Part B Insulin drugs$35 copay (Authorization is required.) (Not applicable.)

Inpatient hospital coverage

$300 per day for days 1 through 5
$0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.)

Mental health services

Inpatient hospital – psychiatric$300 per day for days 1 through 5
$0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.)
Outpatient group therapy visit with a psychiatrist$30 copay (Authorization is not required.) (Referral is not required.)
Outpatient individual therapy visit with a psychiatrist$30 copay (Authorization is not required.) (Referral is not required.)
Outpatient group therapy visit$30 copay (Authorization is not required.) (Referral is not required.)
Outpatient individual therapy visit$30 copay (Authorization is not required.) (Referral is not required.)

Skilled Nursing Facility

$0 per day for days 1 through 20
$203 per day for days 21 through 56
$0 per day for days 57 through 100 (Authorization is not required.) (Referral is not required.)

Package #1

Monthly Premium$17.80
Deductiblenan

Package #2

Monthly Premium$44.00
Deductiblenan

Optional Benefits

Package #1

Comprehensive dental:Monthly Premium:$19.00
Comprehensive dental:Deductible:N/A

Package #2

Comprehensive dental:Monthly Premium:$44.00
Comprehensive dental:Deductible:N/A

Ready to sign up for MediGold No Premium (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

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