Simpra Advantage (PPO D-SNP) By Simpra Advantage
Simpra Advantage (PPO D-SNP) is a 2020 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 D-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.
2020 Medicare Special Needs Plan Details
Simpra Advantage (PPO D-SNP)
|Special Needs Type:||Dual-Eligible|
|Plan Type:||Local PPO|
|Monthly Premium C+D:||$28.70|
The Simpra Advantage (PPO D-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 D-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.
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 D-SNP) plan has a monthly drug premium of $28.70 and a $435.00 drug deductible. This Simpra Advantage plan offers a $28.70 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 $28.70. 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 Simpra Advantage (PPO D-SNP) medicare insurance plan offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $7.20 for 75% low income subsidy $14.40 for 50% and $21.50 for 25%.
|Part C Premium:||$0.00|
|Part D (Drug) Premium:||$28.70|
|Part D Supplemental Premium||$0.00|
|Total Part D Premium:||$28.70|
|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:||$7.20|
|50% LIS Premium:||$14.40|
|25% LIS Premium:||$21.50|
In 2020 once you and your plan provider have spent $4020 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 25% on generic drugs unless your plan offers additional coverage. This Simpra Advantage plan does not offer additional coverage through the gap.
Simpra Advantage Drug Coverage and Formulary
A formulary is divided into tiers or levels of coverage based on the type or usage of your medication or benefit categories, according to drug costs. Each tier will have a defined out-of-pocket cost that you must pay before receiving the drug. You can see complete 2020 Simpra Advantage (PPO D-SNP) H4091-002 Formulary here.
Health plan deductible
Emergency care/Urgent care
|Urgent care||$0 copay|
Diagnostic procedures/lab services/imaging
|Diagnostic tests and procedures||Out-of-Network||20%|
|Diagnostic tests and procedures||In-Network||$0 copay|
|Lab services||In-Network||$0 copay|
|Diagnostic radiology services (e.g., MRI)||Out-of-Network||20%|
|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 - inner ear||Not covered|
|Hearing aids - outer ear||Not covered|
|Hearing aids - over the ear||Not covered|
|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||Out-of-Network||$0 copay|
|Contact lenses||In-Network||$0 copay|
|Eyeglasses (frames and lenses)||Out-of-Network||$0 copay|
|Eyeglasses (frames and lenses)||In-Network||$0 copay|
|Eyeglass frames||Not covered|
|Eyeglass lenses||Not covered|
Mental health services
|Inpatient hospital - psychiatric||Out-of-Network||Coming soon|
|Inpatient hospital - psychiatric||In-Network||$0 copay|
|Outpatient group therapy visit with a psychiatrist||Out-of-Network||20%|
|Outpatient group therapy visit with a psychiatrist||In-Network||$0 copay|
|Outpatient individual therapy visit with a psychiatrist||Out-of-Network||20%|
|Outpatient individual therapy visit with a psychiatrist||In-Network||$0 copay|
|Outpatient group therapy visit||Out-of-Network||20%|
|Outpatient group therapy visit||In-Network||$0 copay|
|Outpatient individual therapy visit||Out-of-Network||20%|
|Outpatient individual therapy visit||In-Network||$0 copay|
Skilled Nursing Facility
|Occupational therapy visit||Out-of-Network||20%|
|Occupational therapy visit||In-Network||$0 copay|
|Physical therapy and speech and language therapy visit||Out-of-Network||20%|
|Physical therapy and speech and language therapy visit||In-Network||$0 copay|
Other health plan deductibles?
Foot care (podiatry services)
|Foot exams and treatment||Out-of-Network||20%|
|Foot exams and treatment||In-Network||$0 copay|
|Routine foot care||Not covered|
|Durable medical equipment (e.g., wheelchairs, oxygen)||Out-of-Network||20% per item|
|Durable medical equipment (e.g., wheelchairs, oxygen)||In-Network||$0 copay|
|Prosthetics (e.g., braces, artificial limbs)||Out-of-Network||20% per item|
|Prosthetics (e.g., braces, artificial limbs)||In-Network||$0 copay|
|Diabetes supplies||Out-of-Network||20% per item|
|Diabetes supplies||In-Network||$0 copay|
Wellness programs (e.g., fitness, nursing hotline)
Medicare Part B drugs
|Other Part B drugs||Out-of-Network||20%|
|Other Part B drugs||In-Network||$0 copay|
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
|$10,000 In and Out-of-network
Optional supplemental benefits
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
Inpatient hospital coverage
Outpatient hospital coverage
|Out-of-Network||20% per visit|
|Primary||Out-of-Network||20% per visit|
|Specialist||Out-of-Network||20% per visit|
Coverage Area for Simpra Advantage (PPO D-SNP)
Plans as of September 4, 2019.
Star Rating as of October 11, 2019.
Plan Services are 2019 information as reference. 2020 information will be added when released.
Notes: Data are subject to change. All contracts for 2020 have not been finalized. For 2020, 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 2020 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.