Simpra Advantage (PPO I-SNP) By Simpra Advantage

Simpra Advantage (PPO I-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 I-SNP) DS-H4091 is an Institutional SNP (I-SNP). An Institutional SNP is for beneficiaries who live in an institution such as a nursing home or require nursing care at home. If you live in an institution like a nursing home or hospital you can join any Medicare SNP you qualify for or switch plans at any time.

2020 Medicare Special Needs Plan Details

The Simpra Advantage (PPO I-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 I-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 I-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.

Premium Assistance

Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Simpra Advantage (PPO I-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%.

Gap Coverage

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 I-SNP) H4091-001 Formulary here.

Drug Tier	Copay Preferred	Copay Nonpreferred
1	NA	25%

*Initial Coverage Phase and 30 day supply

See the 2020 Simpra Advantage Formulary

2019 Plan Services

(*2020 Plan services will be added when available)

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Health plan deductible

Coming soon

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Emergency care/Urgent care

Emergency		20% per visit (always covered)
Urgent care		20% per visit (always covered)

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Diagnostic procedures/lab services/imaging

Diagnostic tests and procedures	Out-of-Network	20%
Diagnostic tests and procedures	In-Network	20%
Lab services	Out-of-Network	20%
Lab services	In-Network	$0 copay
Diagnostic radiology services (e.g., MRI)	Out-of-Network	20%
Diagnostic radiology services (e.g., MRI)	In-Network	20%
Outpatient x-rays	Out-of-Network	20%
Outpatient x-rays	In-Network	20%

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Hearing

Hearing exam	Out-of-Network	20%
Hearing exam	In-Network	$0 copay
Fitting/evaluation	Out-of-Network	$0 copay
Fitting/evaluation	In-Network	$0 copay
Hearing aids	Out-of-Network	$0 copay
Hearing aids	In-Network	$0 copay

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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	Out-of-Network	$0 copay
Routine eye exam	In-Network	$0 copay
Other		Not covered
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
Upgrades		Not covered

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Mental health services

Inpatient hospital - psychiatric	Out-of-Network	Coming soon
Inpatient hospital - psychiatric	In-Network	Coming soon
Outpatient group therapy visit with a psychiatrist	Out-of-Network	20%
Outpatient group therapy visit with a psychiatrist	In-Network	20%
Outpatient individual therapy visit with a psychiatrist	Out-of-Network	20%
Outpatient individual therapy visit with a psychiatrist	In-Network	20%
Outpatient group therapy visit	Out-of-Network	20%
Outpatient group therapy visit	In-Network	20%
Outpatient individual therapy visit	Out-of-Network	20%
Outpatient individual therapy visit	In-Network	20%

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Skilled Nursing Facility

	Out-of-Network	Coming soon
	In-Network	Coming soon

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Rehabilitation services

Occupational therapy visit	Out-of-Network	20%
Occupational therapy visit	In-Network	20%
Physical therapy and speech and language therapy visit	Out-of-Network	20%
Physical therapy and speech and language therapy visit	In-Network	20%

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Ground ambulance

	Out-of-Network	20%
	In-Network	20%

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Other health plan deductibles?

	In-Network	No

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Transportation

Not covered

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Foot care (podiatry services)

Foot exams and treatment	Out-of-Network	20%
Foot exams and treatment	In-Network	20%
Routine foot care	Out-of-Network	$0 copay
Routine foot care	In-Network	$0 copay

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Medical equipment/supplies

Durable medical equipment (e.g., wheelchairs, oxygen)	Out-of-Network	20% per item
Durable medical equipment (e.g., wheelchairs, oxygen)	In-Network	20% per item
Prosthetics (e.g., braces, artificial limbs)	Out-of-Network	20% per item
Prosthetics (e.g., braces, artificial limbs)	In-Network	20% per item
Diabetes supplies	Out-of-Network	20% per item
Diabetes supplies	In-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	Out-of-Network	20%
Chemotherapy	In-Network	20%
Other Part B drugs	Out-of-Network	20%
Other Part B drugs	In-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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Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

	In-Network	No

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Inpatient hospital coverage

	Out-of-Network	Coming soon
	In-Network	Coming soon

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Outpatient hospital coverage

	Out-of-Network	20% per visit
	In-Network	20% per visit

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Doctor visits

Primary	Out-of-Network	20% per visit
Primary	In-Network	20% per visit
Specialist	Out-of-Network	20% per visit
Specialist	In-Network	20% per visit

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Preventive care

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

Coverage Area for Simpra Advantage (PPO I-SNP)

Source: CMS.

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.