Simpra Advantage (PPO I-SNP) By Simpra Advantage



Simpra Advantage (PPO I-SNP) H4091 001 0 is a 2023 Medicare Advantage Special Needs Plan plan by Simpra Advantage. This plan from Simpra Advantage 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 Simpra Advantage and not Original Medicare. All Medicare SNPs also provide Medicare additional Part-D drug coverage. Simpra Advantage (PPO I-SNP) H4091-001 is an Institutional SNP (I-SNP). An Institutional SNP is for beneficiaries who live in an institution such as a nursing home or require nursing care at home. If you live in an institution like a nursing home or hospital you can join any Medicare SNP you qualify for or switch plans at any time.







2023 Medicare Special Needs Plan Details

Plan Name:Simpra Advantage (PPO I-SNP)
Plan ID:H4091 001 0
Special Needs Type:Institutional
Provider:Simpra Advantage
Plan Year:2023
Plan Type:Local PPO
Monthly Premium C+D:$35.20
Part C Premium:$0
Part D (Drug) Premium:$35.20
Part D Supplemental Premium$0
Total Part D Premium:$35.20
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: H4091-002


The Simpra Advantage (PPO I-SNP) H4091-001 is available to residents to Medicare eligible seniors in Alabama. All Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. Simpra Advantage (PPO I-SNP) is a Local PPO. A preferred provider organization (PPO) is a medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.



How much does Simpra Advantage (PPO I-SNP) cost?


Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Simpra Advantage 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. Simpra Advantage (PPO I-SNP) has a monthly drug premium of $35.20 and a $505.00 drug deductible. This Simpra Advantage plan offers a $35.20 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 Simpra Advantage 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 $35.20. 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.


Simpra Advantage 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 Simpra Advantage 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 Simpra Advantage (PPO I-SNP) medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $8.80 for 75% low-income subsidy $17.60 for 50% and $26.40 for 25%.


Full Assistance Premium:$0
75% Assistance Premium:$8.80
50% Assistance Premium:$17.60
25% Assistance Premium:$26.40


H4091-001 Formulary and Drug Coverage

Simpra Advantage (PPO I-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 25%
The complete Simpra Advantage (PPO I-SNP) H4091-001 Formulary
*Initial Coverage Phase and 30 day supply





2023 Summary of Benefits

The benefit information provided is a summary of what Simpra Advantage (PPO I-SNP) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Simpra Advantage 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
Out-of-Network Vision$0 copay



Eyeglass frames


VisionNot covered



Eyeglass lenses


VisionNot covered



Eyeglasses (frames and lenses)


Out-of-Network Vision$0 copay
In-Network Vision$0 copay



Other


VisionNot covered



Routine eye exam


In-Network Vision$0 copay
Out-of-Network Vision$0 copay



Upgrades


VisionNot covered




TransportationNot covered
In-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
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



Occupational therapy visit


Out-of-Network Rehabilitation services20% coinsurance
In-Network Rehabilitation services20% coinsurance



Physical therapy and speech and language therapy visit


In-Network Rehabilitation services20% coinsurance
Out-of-Network Rehabilitation services20% coinsurance



Cleaning


Preventive dentalNot covered



Dental x-ray(s)


Preventive dentalNot covered



Fluoride treatment


Preventive dentalNot covered



Oral exam


Preventive dentalNot covered




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



Inpatient hospital - psychiatric


In-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
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


In-Network Mental health services20% coinsurance
Out-of-Network Mental health services20% coinsurance



Outpatient group therapy visit with a psychiatrist


In-Network Mental health services20% coinsurance
Out-of-Network Mental health services20% coinsurance



Outpatient individual therapy visit


Out-of-Network Mental health services20% coinsurance
In-Network Mental health services20% coinsurance



Outpatient individual therapy visit with a psychiatrist


In-Network Mental health services20% coinsurance
Out-of-Network Mental health services20% coinsurance



Chemotherapy


In-Network Medicare Part B drugs20% coinsurance
Out-of-Network Medicare Part B drugs20% coinsurance



Other Part B drugs


Out-of-Network Medicare Part B drugs20% coinsurance
In-Network Medicare Part B drugs20% coinsurance



Diabetes supplies


Out-of-Network Medical equipment/supplies20% coinsurance per item
In-Network Medical equipment/supplies20% coinsurance per item



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


Out-of-Network Medical equipment/supplies20% coinsurance per item
In-Network Medical equipment/supplies20% coinsurance per item



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


Out-of-Network Medical equipment/supplies20% coinsurance per item
In-Network Medical equipment/supplies20% coinsurance per item




Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$12,450 In and Out-of-network
$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 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



Fitting/evaluation


Out-of-Network Hearing$0 copay
In-Network Hearing$0 copay



Hearing aids


Out-of-Network Hearing$0 copay
In-Network Hearing$0 copay



Hearing exam


Out-of-Network Hearing20% coinsurance
In-Network Hearing20% coinsurance




Health plan deductible$1,600 per year for inpatient hospital services and $226 for outpatient services with a total plan deductible of $1,826 per year from in-network and out-of-network providers.
In-Network Ground ambulance20% coinsurance
Out-of-Network Ground ambulance20% coinsurance



Foot exams and treatment


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



Routine foot care


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



Emergency


Emergency care/Urgent care20% coinsurance per visit (always covered)



Urgent care


Emergency care/Urgent care20% coinsurance per visit (always covered)



Primary


In-Network Doctor visits20% coinsurance per visit
Out-of-Network Doctor visits20% coinsurance per visit



Specialist


In-Network Doctor visits20% coinsurance per visit
Out-of-Network Doctor visits20% coinsurance per visit



Diagnostic radiology services (e.g., MRI)


In-Network Diagnostic procedures/lab services/imaging20% coinsurance
Out-of-Network Diagnostic procedures/lab services/imaging20% coinsurance



Diagnostic tests and procedures


In-Network Diagnostic procedures/lab services/imaging20% coinsurance
Out-of-Network Diagnostic procedures/lab services/imaging20% coinsurance



Lab services


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



Outpatient x-rays


In-Network Diagnostic procedures/lab services/imaging20% coinsurance
Out-of-Network Diagnostic procedures/lab services/imaging20% coinsurance



Diagnostic services


Comprehensive dentalNot covered



Endodontics


Comprehensive dentalNot covered



Extractions


Comprehensive dentalNot covered



Non-routine services


Comprehensive dentalNot covered



Periodontics


Comprehensive dentalNot covered



Prosthodontics, other oral/maxillofacial surgery, other services


Comprehensive dentalNot covered



Restorative services


Comprehensive dentalNot covered




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 Simpra Advantage (PPO I-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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