Signature Advantage Community (HMO I-SNP) By Signature Advantage (HMO SNP)

Signature Advantage Community (HMO I-SNP) H2400 002 0 is a 2023 Medicare Advantage Special Needs Plan plan by Signature Advantage (HMO SNP). This plan from Signature Advantage (HMO SNP) 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 Signature Advantage (HMO SNP) and not Original Medicare. All Medicare SNPs also provide Medicare additional Part-D drug coverage. Signature Advantage Community (HMO I-SNP) H2400-002 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.

2023 Medicare Special Needs Plan Details

Plan Name:Signature Advantage Community (HMO I-SNP)
Plan ID:H2400 002 0
Special Needs Type:Institutional
Provider:Signature Advantage (HMO SNP)
Plan Year:2023
Plan Type:Local HMO
Monthly Premium C+D:$12.00
Part C Premium:$0
Part D (Drug) Premium:$12.00
Part D Supplemental Premium$0
Total Part D Premium:$12.00
Drug Deductible:$505.00
Tiers with No Deductible:0
Benchmark:below the regional benchmark
Type of Medicare Health Plan:Defined Standard Benefit
Drug Benefit Type:Basic
Gap Coverage:No
Similar Plan: H2400-001

The Signature Advantage Community (HMO I-SNP) H2400-002 is available to residents to Medicare eligible seniors in Kentucky. All Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. Signature Advantage Community (HMO 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.

How much does Signature Advantage Community (HMO I-SNP) cost?

Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Signature Advantage (HMO SNP) charges a $0 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

An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. Signature Advantage Community (HMO I-SNP) has a monthly drug premium of $12.00 and a $505.00 drug deductible. This Signature Advantage (HMO SNP) plan offers a $12.00 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. This Premium covers any enhanced plan benefits offered by Signature Advantage (HMO SNP) 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 $12.00. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Signature Advantage (HMO SNP) Gap Coverage

In 2023 once you and your plan provider have spent $4660 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 prescription drugs unless your plan offers additional coverage. This Signature Advantage (HMO SNP) plan does not offer additional coverage through the gap.

Extra Help Premium Assistance

The Low Income Subsidy (LIS) Extra Helps people with Medicare pay for prescription drugs and lowers the costs of Medicare prescription drug coverage. Income limits are based on the Federal Poverty Level (FPL), which changes every year in February or March. The 2022 income limit is $1,719 ($2,309 for couples) per month. Depending on your income level you may be eligible for a full 75%, 50%, 25% premium assistance. The Signature Advantage Community (HMO I-SNP) medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $3.00 for 75% low-income subsidy $6.00 for 50% and $9.00 for 25%.

Full Assistance Premium:$0
75% Assistance Premium:$3.00
50% Assistance Premium:$6.00
25% Assistance Premium:$9.00

H2400-002 Formulary and Drug Coverage

Signature Advantage Community (HMO I-SNP) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Special Needs Plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.

Drug Tier Copay
Tier 1 NA 25%
The complete Signature Advantage Community (HMO I-SNP) H2400-002 Formulary
*Initial Coverage Phase and 30 day supply

2023 Summary of Benefits

The benefit information provided is a summary of what Signature Advantage Community (HMO I-SNP) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Signature Advantage (HMO SNP) helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

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

Contact lenses

Vision$0 copay

Eyeglass frames

Vision$0 copay

Eyeglass lenses

Vision$0 copay

Eyeglasses (frames and lenses)

Vision$0 copay


Vision$0 copay

Routine eye exam

Vision$0 copay


Vision$0 copay

TransportationNot covered
Skilled Nursing Facility$0 per day for days 1 through 30
$160 per day for days 31 through 100

Occupational therapy visit

Rehabilitation services20% coinsurance

Physical therapy and speech and language therapy visit

Rehabilitation services20% coinsurance


Preventive dental$0 copay

Dental x-ray(s)

Preventive dental$0 copay

Fluoride treatment

Preventive dentalNot covered

Oral exam

Preventive dental$0 copay

Preventive care$0 copay
Outpatient hospital coverage$300 copay per visit
In-Network Other health plan deductibles?No
Optional supplemental benefitsNo

Inpatient hospital - psychiatric

Mental health services$374 per day for days 1 through 5
$0 per day for days 6 through 90

Outpatient group therapy visit

Mental health services$0-40 copay

Outpatient group therapy visit with a psychiatrist

Mental health services20% coinsurance

Outpatient individual therapy visit

Mental health services$0-40 copay

Outpatient individual therapy visit with a psychiatrist

Mental health services20% coinsurance


Medicare Part B drugs20% coinsurance

Other Part B drugs

Medicare Part B drugs20% coinsurance

Diabetes supplies

Medical equipment/supplies$0 copay

Durable medical equipment (e.g., wheelchairs, oxygen)

Medical equipment/supplies20% coinsurance per item

Prosthetics (e.g., braces, artificial limbs)

Medical equipment/supplies20% coinsurance per item

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$8,300 In-network
Inpatient hospital coverage$400 per day for days 1 through 5
$0 per day for days 6 through 90


Hearing$0 copay

Hearing aids

Hearing$0 copay

Hearing exam

Hearing20% coinsurance

Health plan deductible$226 per year for in-network services.
Ground ambulance$300 copay

Foot exams and treatment

Foot care (podiatry services)20% coinsurance

Routine foot care

Foot care (podiatry services)$0 copay


Emergency care/Urgent care20% coinsurance per visit (always covered)

Urgent care

Emergency care/Urgent care$60 copay per visit (always covered)


Doctor visits$0-15 copay per visit


Doctor visits$0-40 copay per visit

Diagnostic radiology services (e.g., MRI)

Diagnostic procedures/lab services/imaging$100-200 copay

Diagnostic tests and procedures

Diagnostic procedures/lab services/imaging0-20% coinsurance

Lab services

Diagnostic procedures/lab services/imaging0-20% coinsurance

Outpatient x-rays

Diagnostic procedures/lab services/imaging$0 copay

Diagnostic services

Comprehensive dentalNot covered


Comprehensive dental20% coinsurance


Comprehensive dental20% coinsurance

Non-routine services

Comprehensive dentalNot covered


Comprehensive dental20% coinsurance

Prosthodontics, other oral/maxillofacial surgery, other services

Comprehensive dental20% coinsurance

Restorative services

Comprehensive dental20% coinsurance

In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?No

Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Special Need Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Signature Advantage Community (HMO I-SNP) requires you to live in that plan’s service area. The service area is listed below:

Source: CMS.

Plans as of Oct 1, 2022.

Last updated on

Notes: Data are subject to change. All contracts for 2023 have not been finalized. For 2023, 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 2023 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.

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