Tribute (HMO-POS SNP) By Superior Select Health Plans
Tribute (HMO-POS SNP) is a 2019 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.
2019 Medicare Special Needs Plan Details
Tribute (HMO-POS SNP)
|Special Needs Type:||Dual-Eligible|
|Provider:||Superior Select Health Plans|
|Plan Type:||Local HMO|
|Monthly Premium C+D:||$23.90|
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.
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 $23.90 and a $415.00 drug deductible. This Superior Select Health Plans plan offers a $23.90 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 $23.90. 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.
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 $6.00 for 75% low income subsidy $11.90 for 50% and $17.90 for 25%.
|Part C Premium:||$0.00|
|Part D (Drug) Premium:||$23.90|
|Part D Supplemental Premium||$0.00|
|Total Part D Premium:||$23.90|
|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:||$6.00|
|50% LIS Premium:||$11.90|
|25% LIS Premium:||$17.90|
|Initial Coverage Limit:||$3820|
In 2019 once you and your plan provider have spent $3,820 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 brand-name drugs and 37% on generic drugs unless your plan offers additional coverage. This Superior Select Health Plans plan does not offer additional coverage through the gap.
Health plan deductible
Emergency care/Urgent care
|Urgent care||$0 copay|
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|
|Hearing aids||Out-of-Network||$0 copay|
|Hearing aids||In-Network||$0 copay|
|Oral exam||Not covered|
|Fluoride treatment||Not covered|
|Dental x-ray(s)||Not covered|
|Non-routine services||Not covered|
|Diagnostic services||Not covered|
|Restorative services||Not covered|
|Prosthodontics, other oral/maxillofacial surgery, other services||Not covered|
|Routine eye exam||Out-of-Network||$0 copay|
|Routine eye exam||In-Network||$0 copay|
|Contact lenses||Not covered|
|Eyeglasses (frames and lenses)||Out-of-Network||$0 copay|
|Eyeglasses (frames and lenses)||In-Network||$0 copay|
|Eyeglass frames||Out-of-Network||$0 copay|
|Eyeglass frames||In-Network||$0 copay|
|Eyeglass lenses||Out-of-Network||$0 copay|
|Eyeglass lenses||In-Network||$0 copay|
Mental health services
|Inpatient hospital - psychiatric||Out-of-Network||Not Applicable|
|Inpatient hospital - psychiatric||In-Network||$0 copay|
|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
|Occupational therapy visit||In-Network||$0 copay|
|Physical therapy and speech and language therapy visit||In-Network||$0 copay|
Other health plan deductibles?
Foot care (podiatry services)
|Foot exams and treatment||In-Network||$0 copay|
|Routine foot care||Not covered|
|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)
Medicare Part B drugs
|Other Part B drugs||In-Network||$0 copay|
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
Optional supplemental benefits
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
Inpatient hospital coverage
Outpatient hospital coverage
Coverage Area for Tribute (HMO-POS SNP)
Plans as of September 2, 2018.
Star Rating as of October 10, 2018.
Notes: Data are subject to change. All contracts for 2019 have not been finalized. For 2019, 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 2019 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.