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

Tribute Select (HMO-POS I-SNP) is a 2020 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 Select (HMO-POS I-SNP) DS-H1587 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 Tribute Select (HMO-POS I-SNP) DS-H1587 is available to residents in Arkansas, and all Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. Tribute Select (HMO-POS I-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 Select (HMO-POS I-SNP) plan has a monthly drug premium of $25.00 and a $435.00 drug deductible. This Superior Select Health Plans plan offers a $25.00 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 $25.00. 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 Select (HMO-POS 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 $6.30 for 75% low income subsidy $12.50 for 50% and $18.80 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 Superior Select Health Plans plan does not offer additional coverage through the gap.

Superior Select Health Plans 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 Tribute Select (HMO-POS I-SNP) H1587-003 Formulary here.

Drug Tier	Copay Preferred	Copay Nonpreferred
1	NA	25%

*Initial Coverage Phase and 30 day supply

See the 2020 Superior Select Health Plans Formulary

2019 Plan Services

(*2020 Plan services will be added when available)

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Health plan deductible

$0

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Emergency care/Urgent care

Emergency		$80 per visit (always covered)
Urgent care		$35 per visit (always covered)

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Diagnostic procedures/lab services/imaging

Diagnostic tests and procedures	In-Network	20%
Lab services	In-Network	$0 copay
Diagnostic radiology services (e.g., MRI)	In-Network	$110-220
Outpatient x-rays	In-Network	0%

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Hearing

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

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Mental health services

Inpatient hospital - psychiatric	Out-of-Network	Not Applicable
Inpatient hospital - psychiatric	In-Network	$300 per day for days 1 through 5 $0 per day for days 6 through 90
Outpatient group therapy visit with a psychiatrist	In-Network	20%
Outpatient individual therapy visit with a psychiatrist	In-Network	20%
Outpatient group therapy visit	In-Network	20%
Outpatient individual therapy visit	In-Network	20%

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Skilled Nursing Facility

	Out-of-Network	Not Applicable
	In-Network	Coming soon

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Rehabilitation services

Occupational therapy visit	In-Network	10%
Physical therapy and speech and language therapy visit	In-Network	10%

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Ground ambulance

	In-Network	$150

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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	In-Network	$35
Routine foot care		Not covered

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Medical equipment/supplies

Durable medical equipment (e.g., wheelchairs, oxygen)	In-Network	10% per item
Prosthetics (e.g., braces, artificial limbs)	In-Network	20% per item
Diabetes supplies	In-Network	$0 copay

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

Covered

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Medicare Part B drugs

Chemotherapy	In-Network	20%
Other Part B drugs	In-Network	20%

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

$3,500 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	Not Applicable
	In-Network	$300 per day for days 1 through 5 $0 per day for days 6 through 90

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Outpatient hospital coverage

	In-Network	20% per visit

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Doctor visits

Primary	In-Network	$0 copay
Specialist	In-Network	$35 per visit

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Preventive care

	In-Network	$0 copay

Ratings for Tribute Select (HMO-POS I-SNP) DS

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in Tribute Select (HMO-POS I-SNP) Plans Performance

Health Plan Customer Service Rating for Tribute Select (HMO-POS I-SNP)

Tribute Select (HMO-POS I-SNP) Drug Plan Customer Service ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Coverage Area for Tribute Select (HMO-POS 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.