2018 Simpra Advantage (PPO SNP) DS-H4091

Simpra Advantage (PPO SNP) By SIMPRA Advantage



Simpra Advantage (PPO SNP) is a 2018 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 SNP) DS-H4091 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.



2018 Medicare Special Needs Plan Details

Plan Name:
Simpra Advantage (PPO SNP)
Plan ID:
DS-H4091
Special Needs Type: Institutional
Provider: SIMPRA Advantage
Plan Year:2018
Plan Type: Local PPO
Monthly Premium C+D: $30.60


COMPARE AND SAVE ON MEDICARE INSURANCE




Coverage Area for Simpra Advantage (PPO SNP)



The Simpra Advantage (PPO SNP) DS-H4091 is available to residents in Alabama, and all Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. Simpra Advantage (PPO 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.

Part-C Premium

SIMPRA Advantage plan charges a $0.00 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

The Simpra Advantage (PPO SNP) plan has a monthly drug premium of $30.60 and a $405.00 drug deductible. This SIMPRA Advantage plan offers a $30.60 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 $0.00 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 $30.60. The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.



Premium Assistance

Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Simpra Advantage (PPO SNP) medicare insurance plan offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $7.60 for 75% low income subsidy $15.30 for 50% and $22.90 for 25%.



Part C Premium: $0.00
Part D (Drug) Premium: $30.60
Part D Supplemental Premium $0.00
Total Part D Premium: $30.60
Drug Deductible: $405.00
Tiers with No Deductible: 0
Benchmark: below the regional benchmark
Type of Medicare Health Plan: Defined Standard Benefit
Drug Benefit Type: Basic
Full LIS Premium: $0.00
75% LIS Premium: $7.60
50% LIS Premium: $15.30
25% LIS Premium: $22.90
Initial Coverage Limit:$3750
Gap Coverage: No


Gap Coverage

In 2018 once you and your plan provider have spent $3,750 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 35% for brand-name drugs and 44% on generic drugs unless your plan offers additional coverage. This SIMPRA Advantage plan does not offer additional coverage through the gap.



Plan Services






Health plan deductible


Coming soon



Diagnostic procedures/lab services/imaging


Diagnostic tests and procedures In-Network 20%
Diagnostic tests and procedures Out-of-Network 20%
Lab services In-Network $0 copay
Lab services Out-of-Network 20%
Diagnostic radiology services (e.g., MRI) In-Network 20%
Diagnostic radiology services (e.g., MRI) Out-of-Network 20%
Outpatient x-rays In-Network 20%
Outpatient x-rays Out-of-Network 20%



Hearing


Hearing exam In-Network $0 copay
Hearing exam Out-of-Network 20%
Fitting/evaluation In-Network $0 copay
Fitting/evaluation Out-of-Network $0 copay
Hearing aids In-Network $0 copay
Hearing aids Out-of-Network $0 copay



Preventive dental


Oral exam Not covered
Cleaning Not covered
Fluoride treatment Not covered
Dental x-ray(s) Not covered



Comprehensive dental


Non-routine services Not covered
Diagnostic services Not covered
Restorative services Not covered
Endodontics Not covered
Periodontics Not covered
Extractions Not covered
Prosthodontics, other oral/maxillofacial surgery, other services Not covered



Vision


Routine eye exam In-Network $0 copay
Routine eye exam Out-of-Network $0 copay
Other Not covered
Contact lenses In-Network $0 copay
Contact lenses Out-of-Network $0 copay
Eyeglasses (frames and lenses) In-Network $0 copay
Eyeglasses (frames and lenses) Out-of-Network $0 copay
Eyeglass frames Not covered
Eyeglass lenses Not covered
Upgrades Not covered



Mental health services


In-Network Coming soon
Out-of-Network Coming soon
Outpatient group therapy visit with a psychiatrist In-Network 20%
Outpatient group therapy visit with a psychiatrist Out-of-Network 20%
Outpatient individual therapy visit with a psychiatrist In-Network 20%
Outpatient individual therapy visit with a psychiatrist Out-of-Network 20%
Outpatient group therapy visit In-Network 20%
Outpatient group therapy visit Out-of-Network 20%
Outpatient individual therapy visit In-Network 20%
Outpatient individual therapy visit Out-of-Network 20%



Skilled Nursing Facility


In-Network Coming soon
Out-of-Network Coming soon



Rehabilitation services


Occupational therapy visit In-Network 20%
Occupational therapy visit Out-of-Network 20%
Physical therapy and speech and language therapy visit In-Network 20%
Physical therapy and speech and language therapy visit Out-of-Network 20%



Ambulance


In-Network 20%
Out-of-Network 20%



Transportation


Not covered



Other health plan deductibles?


In-Network No



Foot care (podiatry services)


Foot exams and treatment In-Network 20%
Foot exams and treatment Out-of-Network 20%
Routine foot care In-Network $0 copay
Routine foot care Out-of-Network $0 copay



Medical equipment/supplies


Durable medical equipment (e.g., wheelchairs, oxygen) In-Network 20% per item
Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-Network 20% per item
Prosthetics (e.g., braces, artificial limbs) In-Network 20% per item
Prosthetics (e.g., braces, artificial limbs) Out-of-Network 20% per item
Diabetes supplies In-Network 20% per item
Diabetes supplies Out-of-Network 20% per item



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


Not covered



Medicare Part B drugs


Chemotherapy In-Network 20%
Chemotherapy Out-of-Network 20%
Other Part B drugs In-Network 20%
Other Part B drugs Out-of-Network 20%



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


$10,000 In and Out-of-network
$6,700 In-network



Optional supplemental benefits


No



Inpatient hospital coverage


In-Network Coming soon
Out-of-Network Coming soon



Outpatient hospital coverage


In-Network 20% per visit
Out-of-Network 20% per visit



Doctor visits


Primary In-Network 20% per visit
Primary Out-of-Network 20% per visit
Specialist In-Network 20% per visit
Specialist Out-of-Network 20% per visit



Preventive care


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



Emergency care/Urgent care


Emergency 20% per visit (always covered)
Urgent care 20% per visit (always covered)




Ratings for Simpra Advantage (PPO SNP) DS

2018 Overall Rating
Part C Summary Rating
Part D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing


Member Experience with Health Plan

Total Experience Rating
Getting Needed Care
Timely Care and Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination


Member Complaints and Changes in Simpra Advantage (PPO SNP) Plans Performance

Total Rating
Members Leaving the Plan
Complaints about Health Plan
Beneficiary Access
Health Plan Quality Improvement


Health Plan Customer Service Rating for Simpra Advantage (PPO SNP)

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language


Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Improving Physical
Improving Mental Health
Monitoring Physical Activity
Adult BMI Assessment


Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
Pain Screening
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Controlling Blood Pressure
Rheumatoid Arthritis
Improving Bladder Control
Reducing Risk of Falling
Plan - Cause Readmissions


Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs


Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR


Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Beneficiary Access
Drug Plan Quality Improvement


Simpra Advantage (PPO SNP) Drug Plan Customer Service ratings

Total Rating
Appeals Auto Forward
Appeals Upheld
Call Center, TTY, Foreign Language


Source: CMS.

Plans as of September 2, 2017.

Star Rating as of September 6, 2017.

For More Information on Ratings Please See the CMS Tech Notes Here.

Notes: Data are subject to change. All contracts for 2018 have not been finalized. For 2018, 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 2018 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.

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