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

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%.

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

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Health plan deductible

$0

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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%

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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

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Preventive dental

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

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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

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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

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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%

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Skilled Nursing Facility

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

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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%

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Ambulance

	In-Network	$0 copay
	Out-of-Network	20%

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Transportation

Not covered

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Other health plan deductibles?

	In-Network	No

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Foot care (podiatry services)

Foot exams and treatment	In-Network	$0 copay
Foot exams and treatment	Out-of-Network	20%
Routine foot care		Not covered

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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

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

Not covered

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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%

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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

No

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Inpatient hospital coverage

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

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Outpatient hospital coverage

	In-Network	$0 copay
	Out-of-Network	20% per visit

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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

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Preventive care

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

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Emergency care/Urgent care

Emergency		$0 copay
Urgent care		$0 copay

Ratings for Simpra Advantage (PPO SNP) DS

Member Experience with Health Plan

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

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

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ratings For Member Complaints and Changes in the Drug Plans Performance

Simpra Advantage (PPO SNP) Drug Plan Customer Service ratings

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.