Tribute Advantage (HMO-POS D-SNP) By Tribute Health Plans



Tribute Advantage (HMO-POS D-SNP) H1587 001 0 is a 2023 Medicare Advantage Special Needs Plan plan by Tribute Health Plans. This plan from Tribute Health Plans works with Medicare to give you significant coverage beyond original Medicare. If you decide to sign up you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Tribute Health Plans and not Original Medicare. All Medicare SNPs also provide Medicare additional Part-D drug coverage. Tribute Advantage (HMO-POS D-SNP) H1587-001 is a Dual Eligible Special Needs Plan (D-SNP). A Dual Eligible SNP is for beneficiaries who are eligible for both Medicare and Medicaid. If you have Medicare and get help from Medicaid you can join any Medicare SNP you qualify for or switch plans at any time.







2023 Medicare Special Needs Plan Details

Plan Name:Tribute Advantage (HMO-POS D-SNP)
Plan ID:H1587 001 0
Special Needs Type:Dual-Eligible
Provider:Tribute Health Plans
Plan Year:2023
Plan Type:Local HMO
Monthly Premium C+D:$31.90
Part C Premium:$0
Part D (Drug) Premium:$31.90
Part D Supplemental Premium$0
Total Part D Premium:$31.90
Drug Deductible:$505.00
Tiers with No Deductible:0
Benchmark:below the regional benchmark
Type of Medicare Health Plan:Defined Standard Benefit
Drug Benefit Type:Basic
Gap Coverage:No
Similar Plan: H1587-003


The Tribute Advantage (HMO-POS D-SNP) H1587-001 is available to residents to Medicare eligible seniors in Arkansas. All Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. Tribute Advantage (HMO-POS D-SNP) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you need special care for a physician specialist, your primary care physician will make the arrangements and tell you where you can go in the network. You will need your PCPs okay, called a referral. Without getting a referral or services received from out-of-network providers are not typically covered by the plan.



How much does Tribute Advantage (HMO-POS D-SNP) cost?


Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Tribute Health Plans charges a $0 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.


Part-D Deductible and Premium

An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. Tribute Advantage (HMO-POS D-SNP) has a monthly drug premium of $31.90 and a $505.00 drug deductible. This Tribute Health Plans plan offers a $31.90 Part-D Basic Premium that is below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0. This Premium covers any enhanced plan benefits offered by Tribute Health Plans above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $31.90. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.


Tribute Health Plans Gap Coverage

In 2023 once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Tribute Health Plans plan does not offer additional coverage through the gap.


Extra Help Premium Assistance

The Low Income Subsidy (LIS) Extra Helps people with Medicare pay for prescription drugs and lowers the costs of Medicare prescription drug coverage. Income limits are based on the Federal Poverty Level (FPL), which changes every year in February or March. The 2022 income limit is $1,719 ($2,309 for couples) per month. Depending on your income level you may be eligible for a full 75%, 50%, 25% premium assistance. The Tribute Advantage (HMO-POS D-SNP) medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $8.00 for 75% low-income subsidy $15.90 for 50% and $23.90 for 25%.


Full Assistance Premium:$0
75% Assistance Premium:$8.00
50% Assistance Premium:$15.90
25% Assistance Premium:$23.90


H1587-001 Formulary and Drug Coverage

Tribute Advantage (HMO-POS D-SNP) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Special Needs Plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.

Drug Tier Copay
Preferred
Pharmacy
Copay
Nonpreferred
Pharmacy
Tier 1 NA $0
The complete Tribute Advantage (HMO-POS D-SNP) H1587-001 Formulary
*Initial Coverage Phase and 30 day supply





2023 Summary of Benefits

The benefit information provided is a summary of what Tribute Advantage (HMO-POS D-SNP) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Tribute Health Plans helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

Wellness programs (e.g., fitness, nursing hotline)Not covered



Contact lenses


In-Network Vision$0 copay



Eyeglass frames


In-Network Vision$0 copay



Eyeglass lenses


In-Network Vision$0 copay



Eyeglasses (frames and lenses)


In-Network Vision$0 copay



Other


VisionNot covered



Routine eye exam


In-Network Vision$0 copay



Upgrades


In-Network Vision$0 copay




TransportationNot covered
Out-of-Network Skilled Nursing FacilityIn 2023 the amounts for each benefit period are:
$0 copay for days 1 through 20
$200 copay per day for days 21 through 100
In-Network Skilled Nursing Facility$0 copay



Occupational therapy visit


Out-of-Network Rehabilitation services20% coinsurance
In-Network Rehabilitation services$0 copay



Physical therapy and speech and language therapy visit


Out-of-Network Rehabilitation services20% coinsurance
In-Network Rehabilitation services$0 copay



Cleaning


In-Network Preventive dental$0 copay



Dental x-ray(s)


In-Network Preventive dental$0 copay



Fluoride treatment


In-Network Preventive dental$0 copay



Oral exam


In-Network Preventive dental$0 copay




In-Network Preventive care$0 copay
Out-of-Network Preventive care20% coinsurance
In-Network Outpatient hospital coverage$0 copay
Out-of-Network Outpatient hospital coverage20% coinsurance per visit
In-Network Other health plan deductibles?No
Optional supplemental benefitsNo



Inpatient hospital - psychiatric


In-Network Mental health services$0 copay
Out-of-Network Mental health servicesIn 2023 the amounts for each benefit period are:
$1,600 deductible for days 1 through 60
$400 copay per day for days 61 through 90



Outpatient group therapy visit


Out-of-Network Mental health services20% coinsurance
In-Network Mental health services$0 copay



Outpatient group therapy visit with a psychiatrist


In-Network Mental health services$0 copay
Out-of-Network Mental health services20% coinsurance



Outpatient individual therapy visit


In-Network Mental health services$0 copay
Out-of-Network Mental health services20% coinsurance



Outpatient individual therapy visit with a psychiatrist


In-Network Mental health services$0 copay
Out-of-Network Mental health services20% coinsurance



Chemotherapy


Out-of-Network Medicare Part B drugs20% coinsurance
In-Network Medicare Part B drugs$0 copay



Other Part B drugs


In-Network Medicare Part B drugs$0 copay
Out-of-Network Medicare Part B drugs20% coinsurance



Diabetes supplies


In-Network Medical equipment/supplies$0 copay
Out-of-Network Medical equipment/supplies20% coinsurance per item



Durable medical equipment (e.g., wheelchairs, oxygen)


In-Network Medical equipment/supplies$0 copay
Out-of-Network Medical equipment/supplies20% coinsurance per item



Prosthetics (e.g., braces, artificial limbs)


In-Network Medical equipment/supplies$0 copay
Out-of-Network Medical equipment/supplies20% coinsurance per item




Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$8,300 In-network
Out-of-Network Inpatient hospital coverageIn 2023 the amounts for each benefit period are:
$1,600 deductible for days 1 through 60
$400 copay per day for days 61 through 90
In-Network Inpatient hospital coverage$0 copay



Fitting/evaluation


In-Network Hearing$0 copay



Hearing aids


In-Network Hearing$0 copay



Hearing exam


In-Network Hearing$0 copay
Out-of-Network Hearing20% coinsurance




Health plan deductible$0
In-Network Ground ambulance$0 copay
Out-of-Network Ground ambulance20% coinsurance



Foot exams and treatment


In-Network Foot care (podiatry services)$0 copay
Out-of-Network Foot care (podiatry services)20% coinsurance



Routine foot care


Foot care (podiatry services)Not covered



Emergency


Emergency care/Urgent care$0 copay



Urgent care


Emergency care/Urgent care$0 copay



Primary


Out-of-Network Doctor visits20% coinsurance per visit
In-Network Doctor visits$0 copay



Specialist


In-Network Doctor visits$0 copay
Out-of-Network Doctor visits20% coinsurance per visit



Diagnostic radiology services (e.g., MRI)


In-Network Diagnostic procedures/lab services/imaging$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging20% coinsurance



Diagnostic tests and procedures


In-Network Diagnostic procedures/lab services/imaging$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging20% coinsurance



Lab services


In-Network Diagnostic procedures/lab services/imaging$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging20% coinsurance



Outpatient x-rays


In-Network Diagnostic procedures/lab services/imaging$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging20% coinsurance



Diagnostic services


In-Network Comprehensive dental$0 copay



Endodontics


In-Network Comprehensive dental$0 copay



Extractions


In-Network Comprehensive dental$0 copay



Non-routine services


In-Network Comprehensive dental$0 copay



Periodontics


In-Network Comprehensive dental$0 copay



Prosthodontics, other oral/maxillofacial surgery, other services


In-Network Comprehensive dental$0 copay



Restorative services


In-Network Comprehensive dental$0 copay




In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?No




Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Special Need Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Tribute Advantage (HMO-POS D-SNP) requires you to live in that plan’s service area. The service area is listed below:





Source: CMS.

Plans as of Oct 1, 2022.

Last updated on

Notes: Data are subject to change. All contracts for 2023 have not been finalized. For 2023, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part Part D benefit.

Includes 2023 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.

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