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 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.
2018 Medicare Special Needs Plan Details
Plan Name: | Simpra Advantage (PPO SNP) |
Plan ID: | DS-H4091 |
Special Needs Type: | Dual-Eligible |
Provider: | SIMPRA Advantage |
Plan Year: | 2018 |
Plan Type: | Local PPO |
Monthly Premium C+D: | $30.60 |
Coverage Area for Simpra Advantage (PPO SNP)
State: |
Alabama
County: | Autauga, Baldwin, Barbour, Bibb, Blount, Bullock, Butler, Calhoun, Chambers, Cherokee, Chilton, Choctaw, Clarke, Clay, Cleburne, Coffee, Colbert, Conecuh, Coosa, Covington, Crenshaw, Cullman, Dale, Dallas, DeKalb, Elmore, Escambia, Etowah, Fayette, Franklin, Geneva, Greene, Hale, Henry, Houston, Jackson, Jefferson, Lamar, Lauderdale, Lawrence, Lee, Limestone, Lowndes, Macon, Madison, Marengo, Marion, Marshall, Mobile, Monroe, Montgomery, Morgan, Perry, Pickens, Pike, Randolph, Russell, Shelby, St. Clair, Sumter, Talladega, Tallapoosa, Tuscaloosa, Walker, Washington, Wilcox, Winston,
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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 |
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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 |
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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
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures |
In-Network |
$0 copay |
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 |
$0 copay |
Diagnostic radiology services (e.g., MRI) |
Out-of-Network |
20% |
Outpatient x-rays |
In-Network |
$0 copay |
Outpatient x-rays |
Out-of-Network |
20% |
Hearing
Hearing exam |
In-Network |
$0 copay |
Hearing exam |
Out-of-Network |
20% |
Fitting/evaluation |
|
Not covered |
Hearing aids - inner ear |
|
Not covered |
Hearing aids - outer ear |
|
Not covered |
Hearing aids - over the ear |
|
Not covered |
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 |
$0 copay |
|
Out-of-Network |
Coming soon |
Outpatient group therapy visit with a psychiatrist |
In-Network |
$0 copay |
Outpatient group therapy visit with a psychiatrist |
Out-of-Network |
20% |
Outpatient individual therapy visit with a psychiatrist |
In-Network |
$0 copay |
Outpatient individual therapy visit with a psychiatrist |
Out-of-Network |
20% |
Outpatient group therapy visit |
In-Network |
$0 copay |
Outpatient group therapy visit |
Out-of-Network |
20% |
Outpatient individual therapy visit |
In-Network |
$0 copay |
Outpatient individual therapy visit |
Out-of-Network |
20% |
Skilled Nursing Facility
|
In-Network |
$0 copay |
|
Out-of-Network |
Coming soon |
Rehabilitation services
Occupational therapy visit |
In-Network |
$0 copay |
Occupational therapy visit |
Out-of-Network |
20% |
Physical therapy and speech and language therapy visit |
In-Network |
$0 copay |
Physical therapy and speech and language therapy visit |
Out-of-Network |
20% |
Ambulance
|
In-Network |
$0 copay |
|
Out-of-Network |
20% |
Transportation
Other health plan deductibles?
Foot care (podiatry services)
Foot exams and treatment |
In-Network |
$0 copay |
Foot exams and treatment |
Out-of-Network |
20% |
Routine foot care |
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Not covered |
Medical equipment/supplies
Durable medical equipment (e.g., wheelchairs, oxygen) |
In-Network |
$0 copay |
Durable medical equipment (e.g., wheelchairs, oxygen) |
Out-of-Network |
20% per item |
Prosthetics (e.g., braces, artificial limbs) |
In-Network |
$0 copay |
Prosthetics (e.g., braces, artificial limbs) |
Out-of-Network |
20% per item |
Diabetes supplies |
In-Network |
$0 copay |
Diabetes supplies |
Out-of-Network |
20% per item |
Wellness programs (e.g., fitness, nursing hotline)
Medicare Part B drugs
Chemotherapy |
In-Network |
$0 copay |
Chemotherapy |
Out-of-Network |
20% |
Other Part B drugs |
In-Network |
$0 copay |
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 |
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Optional supplemental benefits
Inpatient hospital coverage
|
In-Network |
$0 copay |
|
Out-of-Network |
Coming soon |
Outpatient hospital coverage
|
In-Network |
$0 copay |
|
Out-of-Network |
20% per visit |
Doctor visits
Primary |
In-Network |
$0 copay |
Primary |
Out-of-Network |
20% per visit |
Specialist |
In-Network |
$0 copay |
Specialist |
Out-of-Network |
20% per visit |
Preventive care
|
In-Network |
$0 copay |
|
Out-of-Network |
$0 copay |
Emergency care/Urgent care
Emergency |
|
$0 copay |
Urgent care |
|
$0 copay |
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.