2024 Member Resources & Forms
Evidence of Coverage
Learn about evidence of coverage for Arizona and Florida for each Gold Kidney Health Plan.
2024 Plan Comparison
Coming by 10/15/2023. Please check back!
2024 Plan Comparison Chart
All of our 2024 plans at-a-glance
2024 Summary of Benefits
Super Plus/Super Complete
For those with cardiovascular disorders, chronic heart failure, and/or diabetes. Super Plus is designed for Medicare members and Super Complete is designed for members with Medicare and Medicaid.
Dialysis Plus/Dialysis Complete
For those with End-Stage Renal Disease (ESRD) requiring any mode of dialysis. Dialysis Plus is designed for Medicare members and Dialysis Complete is designed for members with Medicare and Medicaid.
Honest Care
For those without chronic conditions who are seeking a plan with extra benefits and the flexibility to see the doctor of their choice with no referral required.
Essential Care
For those with existing prescription drug coverage who need only a few supplemental benefits.
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Loyalty Care
This medical plan is for people who have separate prescription drug coverage.
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Spanish
2024 Benefits Beyond Medicare
Flex Card Benefits
Our Medicare Advantage plans include dental, hearing, vision, and more. Members are able to choose their providers without being concerned about whether they are in or out of network.
Flex card benefits include:
- Dental, hearing and vision
- Rewards and incentives
- Special supplemental benefits for the chronically ill
- Over-the-Counter (OTC) medication
Members receive a quarterly allowance for benefits. Generally, quarterly allowance balances do not roll from quarter.
Transportation
Gold Kidney provides transportation benefits through an easy-to-use app that can be used for scheduling trips, or requesting on-demand trips.
Gold Kidney provides non-emergency transportation options for members with various mobility needs. Members can call or use an app on their phone to manage all their transportation needs, including the following services:
- Curb to curb
- Door to door
- Hand to hand
- Wheelchair
- Stretcher
- Non-emergency ambulance
No prior authorization is required, and one companion is allowed to accompany our members.
Companion Care
Our member benefits include support for everyday tasks or companionship needs.
We help connect members and their families to individuals who can provide companionship or help with everyday chores and tasks like grocery shopping, light housekeeping or yardwork, and technology assistance.
Fitness
Gold Kidney offers the most comprehensive exercise and healthy aging programs available in the market through Silver&Fit.
Gold Kidney has partnered with Silver&Fit to provide members with a variety of exercise and well-being options, including:
- Fitness center memberships – at gyms, exercise studios, and outdoor fitness programs
- Virtual personal training and home fitness kits
- Digital well-being resources and in-person healthy aging classes
Meal Delivery
Gold Kidney offers meals to help those with chronic conditions manage their conditions or those recovering from a hospital stay.
Home–delivered meals, designed by professional chefs and registered dieticians, for members who need help managing the nutritional aspects of their health conditions or who may need assistance with meals after surgery or hospital stay. Two meals per day for 14 days up to 4 times per year.
Personal Emergency Response System
Gold Kidney provides a device for the member to be immediately connected with professionally trained operators who quickly assess the nature of a call and coordinate appropriate assistance.
Nurse Advice Line
A dedicated service staffed by qualified and experienced nurses who provide medical assistance and guidance over the phone when members need it.
Nurse Advice Lines are available 24/7 to help answer your questions or provide triage and referral services.
Remote Patient Monitoring
Gold Kidney offers remote patient monitoring services to remotely manage chronic health conditions from the comfort of our members’ homes.
Gold Kidney offers a platform that Includes an AI virtual health assistant, and clinical Insights and analytics that provide more Informed clinical decision-making, earlier Interventions, and better care.
The monitored services can include a weight scale, blood pressure cuff, glucose monitor, and pulse oximeter.
Transplant Services
Gold Kidney offers access to transplant Centers of Excellence.
2024 Forms & Documents
Enrollment Form
Click here to sign up for one of our Medicare Advantage plans.
Condition Verification C-SNP Form
Access forms required to qualify for Chronic Condition Special Needs Plans.
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Pre-Enrollment Checklist
Find a list of everything you will need to have on hand before enrolling.
Member Attestation Form
Certifies that you are eligible to enroll during an enrollment period.
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Authorized Representative Form
Authorizes representation by a third party on your behalf.
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Spanish
Health Risk Assessment (HRA) Form
Answer questions to help us better meet your care needs.
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Premium Payment Authorization Form
Complete this form to authorize the automatic deduction of premium payments from your Social Security or Railroad Retirement Board benefit check.
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Member Reimbursement Form
Use this when you are seeking reimbursement for out-of-pocket expenses you’ve incurred for covered services.
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Medication Therapy Management (MTM)
For those in a Medicare drug plan that have complex health needs.
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Formulary Drug List
A drug formulary is a list of covered prescription medications.
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Spanish
Appeals
Grievances
Appeals to our Plan (Appeal Level 1)
You may ask us to review our coverage determination (Part D) or organization determination (Part C), even if only part of our decision is not what you requested. An appeal to our plan about a Part D drug is also called a plan “Redetermination.” An appeal about a medical care decision is called a plan “Reconsideration.” When we review your appeal, we look carefully at the information about your request for an exception to Part D coverage rules or for coverage of medical care to ensure we were fair and that we followed all applicable rules when we made our initial decision.
Who may file your appeal of the coverage or organization determination?
When you appeal a coverage determination about a Part D drug or an organization determination for Part C medical care or services, you, your representative, or your doctor may file a standard appeal request or a fast appeal request.
How soon must you file your appeal?
You must file the appeal request within 60 days from the date included on the notice of our coverage determination or organization determination. We may give you more time if you have a good reason (also known as Good Cause) for missing the deadline
How to file your appeal
Asking for a standard appeal
To ask for a “standard” or “fast” appeal for a Part D drug or Part C medical care or services, you, your doctor or your representative should use the following contact information:
For Part C Appeals (about your medical care services):
Mailing Address:
Gold Kidney Health Plan Inc.
Attention: Utilization Management Dept.
P.O. Box 14050
Scottsdale, AZ 85267
Phone: 1-844-294-6535
TYY Users: 711
Fax: 1-866-515-7869 Attention: Gold Kidney Appeals & Grievances Department
For Part D Appeals (about Part D prescription drugs):
Mailing Address:
MedImpact
Attention: Appeals & Grievances Dept.
10181 Scripps Gateway Court
San Diego, CA 92131
Phone: 888-672-7206
Fax: 858-790-6060
Webpage: https://mp.medimpact.com/partdappeal
For standard Part D appeals, we must inform you of our decision within 7 days after receiving your appeal (sooner if your health requires a faster decision). If we fail to do so, we must send your appeal to Level 2 in the appeals process.
For fast and standard Part D appeals, if we deny your Level 1 appeal to our plan, you may choose to accept the denial, or you may make another appeal. This appeal would be a Level 2 appeal. At this level, an outside Independent Review Organization with no connection to our plan reviews our decision and decides whether to uphold it or change it.
Asking for a fast appeal
If you are appealing a decision we made about giving you a Part D drug or Part C medical care or services you have not received yet, you and/or your doctor will need to decide if you need a fast (or “expedited”) appeal. The requirements for receiving a fast appeal are the same as those for receiving a fast coverage decision. If your doctor provides a written or oral statement explaining your need for a fast appeal, we will automatically give you one.
For Part C and Part D fast appeals, we must give you our decision within 72 hours after receiving your appeal. For Part C appeals only, we may take up to 14 more days if you request more time or if we need more information to make our decision. If we do not meet these guidelines, we must send your appeal to Appeal Level 2. To request a fast appeal outside of regular business hours, please fax your request to the fax numbers shown in the “Asking for a standard appeal” section above.
Additional appeal rights
Provided you meet certain rules, you may be able to continue up to 5 levels of appeal. Please see our plan’s Evidence of Coverage for more information about these additional appeal levels. You also have appeal rights if you believe you are being released from a hospital too soon or you believe coverage for home health, skilled nursing or outpatient rehabilitation care is ending too soon. The Evidence of Coverage also has information about these types of appeals, so please consult your Evidence of Coverage or contact our Member Services Department at 1-844-294-6535, 8:00 A.M. – 5:00 P.M., Monday – Friday.
Your right to make complaints
As a member of our plan, you have the right to make a complaint (also called “filing a grievance”) for certain types of problems not related to benefits, coverage, or payment.
Here are some examples of problems that are handled through the grievance process:
- You are not satisfied with the quality of medical care you receive,
- You are unhappy with the cleanliness of one of our network pharmacies, doctor’s offices or clinics,
- You experience excessive waiting times (for example, you have trouble getting a doctor’s appointment or you have to wait too long in a doctor’s office, at a pharmacy or to speak to a Member Services representative),
- You feel that someone did not respect your privacy rights, or
- You are dissatisfied with our timeliness in responding to coverage decisions and appeals you have asked for
Link to Medicare.gov to file a complaint
Coverage Decisions
You, your prescribing physician, or someone you name may ask us for a coverage determination. Other persons may be authorized under state law to act on your behalf.
For Part C Organization Determinations:
Gold Kidney Health Plan Inc.
Attention: Utilization Management Dept.
P.O. Box 14050
Scottsdale, AZ 85267
Phone: 1-844-294-6535
TTY Users: 711
Fax: 1-866-515-7869 Attention: Utilization Management Dept.
For Part D Coverage Determinations:
MedImpact
Attention: Appeals & Grievances Dept.
10181 Scripps Gateway Court
San Diego, CA 92131
Fax: 858-790-6060
Webpage: https://mp.medimpact.com/partdappeal
For Part C Coverage Determinations:
Mailing Address:
Gold Kidney Health Plan Inc.
Attention: Utilization Management Dept.
P.O. Box 14050
Scottsdale, AZ 85267
TYY Users: 711
Fax: 1-866-515-7869
Attention: Utilization Management Dept.
Disenrollment Rights & Responsibilities
Learn your rights and responsibilities to disenroll from Gold Kidney Health Plans.