2018 Tribute (HMO-POS SNP) DS-H1587

Tribute (HMO-POS SNP) By Superior Select Health Plans

Tribute (HMO-POS SNP) is a 2018 Medicare Advantage Special Needs Plan plan by Superior Select Health Plans. This plan from Superior Select 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 Superior Select Health Plans and not Original Medicare. All Medicare SNPs also provide Medicare additional Part-D drug coverage. Tribute (HMO-POS SNP) DS-H1587 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:
Tribute (HMO-POS SNP)
Plan ID:
Special Needs Type: Dual-Eligible
Provider: Superior Select Health Plans
Plan Year:2018
Plan Type: Local HMO
Monthly Premium C+D: $22.60


Coverage Area for Tribute (HMO-POS SNP)

The Tribute (HMO-POS SNP) DS-H1587 is available to residents in Arkansas, and all Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. Tribute (HMO-POS 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.

Part-C Premium

Superior Select Health Plans 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 Tribute (HMO-POS SNP) plan has a monthly drug premium of $22.60 and a $405.00 drug deductible. This Superior Select Health Plans plan offers a $22.60 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 Superior Select 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 $22.60. 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 Tribute (HMO-POS SNP) medicare insurance plan offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $5.70 for 75% low income subsidy $11.30 for 50% and $17.00 for 25%.

Part C Premium: $0.00
Part D (Drug) Premium: $22.60
Part D Supplemental Premium $0.00
Total Part D Premium: $22.60
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: $5.70
50% LIS Premium: $11.30
25% LIS Premium: $17.00
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 Superior Select Health Plans 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
Lab services In-Network $0 copay
Diagnostic radiology services (e.g., MRI) In-Network $0 copay
Outpatient x-rays In-Network $0 copay


Hearing exam In-Network $0 copay
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 In-Network $0 copay
Oral exam Out-of-Network $0 copay
Cleaning In-Network $0 copay
Cleaning Out-of-Network $0 copay
Fluoride treatment In-Network $0 copay
Fluoride treatment Out-of-Network $0 copay
Dental x-ray(s) In-Network $0 copay
Dental x-ray(s) Out-of-Network $0 copay

Comprehensive dental

Non-routine services In-Network $0 copay
Non-routine services Out-of-Network $0 copay
Diagnostic services In-Network $0 copay
Diagnostic services Out-of-Network $0 copay
Restorative services In-Network $0 copay
Restorative services Out-of-Network $0 copay
Endodontics In-Network $0 copay
Endodontics Out-of-Network $0 copay
Periodontics In-Network $0 copay
Periodontics Out-of-Network $0 copay
Extractions In-Network $0 copay
Extractions Out-of-Network $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services In-Network $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Out-of-Network $0 copay


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

Mental health services

In-Network $0 copay
Out-of-Network Not Applicable
Outpatient group therapy visit with a psychiatrist In-Network $0 copay
Outpatient individual therapy visit with a psychiatrist In-Network $0 copay
Outpatient group therapy visit In-Network $0 copay
Outpatient individual therapy visit In-Network $0 copay

Skilled Nursing Facility

In-Network $0 copay
Out-of-Network Not Applicable

Rehabilitation services

Occupational therapy visit In-Network $0 copay
Physical therapy and speech and language therapy visit In-Network $0 copay


In-Network $0 copay


In-Network $0 copay

Other health plan deductibles?

In-Network No

Foot care (podiatry services)

Foot exams and treatment In-Network $0 copay
Routine foot care Not covered

Medical equipment/supplies

Durable medical equipment (e.g., wheelchairs, oxygen) In-Network $0 copay
Prosthetics (e.g., braces, artificial limbs) In-Network $0 copay
Diabetes supplies In-Network $0 copay

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

Not covered

Medicare Part B drugs

Chemotherapy In-Network $0 copay
Other Part B drugs In-Network $0 copay

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

$6,700 In-network

Optional supplemental benefits


Inpatient hospital coverage

In-Network $0 copay
Out-of-Network Not Applicable

Outpatient hospital coverage

In-Network $0 copay

Doctor visits

Primary In-Network $0 copay
Specialist In-Network $0 copay

Preventive care

In-Network $0 copay

Emergency care/Urgent care

Emergency $0 copay
Urgent care $0 copay

Ratings for Tribute (HMO-POS 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 Tribute (HMO-POS 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 Tribute (HMO-POS 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

Tribute (HMO-POS 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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