This guide is intended to give you an overview of your Simplete ® benefits, perks and common costs. If you have a specific question about your premiums or coverage, refer to the booklet for more plan information.
Comfort of having an in-network primary care provider to oversee all your care.
Generally gives you the flexibility to see any doctor who accepts Original Medicare.
Replaces Original Medicare.
Supplements Original Medicare.
May cover benefits that Original Medicare doesn’t.
Only covers expenses covered by Original Medicare.
No medical underwriting.
Medical underwriting. (except for guaranteed issue plans)
Lower premiums than Medicare Supplement plans.
Higher premiums than Medicare Advantage plans.
Who pays in what order: health plan, you. Not age- or tobacco-rated.
Who pays in what order: Original Medicare, health plan, you. Age- and tobacco-rated.
Ambulance: What you pay for an ambulance ride in an emergency.
Copayment/coinsurance: The set dollar amount or percentage you pay for a doctor’s visit, at the hospital or at the pharmacy. Copayment is a specific dollar amount (like $20), and coinsurance is a percentage (like 20%).
Drug tier: The cost group a drug belongs to. Drugs in our Medicare Part D formulary are in one of five groups:
Tier 1 (Preferred Generic).
•
• Tier 2 (Generic).
• Tier 3 (Preferred Brand).
• Tier 4 (Non-Preferred Drug).
• Tier 5 (Specialty Tier).
Generally, the higher the tier, the more you pay for the drug. Some prescriptions require step therapy (for you to try a lower tier first), prior authorization or a limit on the amount you can receive at one time. If your drug isn’t covered, you can ask for an exception. For more information, see the formulary.
Emergency care: The amount you pay for emergency care, like a trip to the emergency department.
Inpatient hospital care: The amount you pay for a stay in an in-network hospital.*
Lab: What you pay for lab services, like blood tests.
Medical deductible: What you pay out-of-pocket before your coverage starts. Our plans don’t have medical deductibles.
Outpatient surgery: What you pay for an outpatient procedure.
Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare.
Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium.
Primary care provider (PCP) visit: The amount you pay at the doctor’s office when you visit your in-network primary care doctor.*
Skilled nursing facility (SNF): What you pay for an approved stay at a SNF.
Specialist visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.*
Urgent care: The amount you pay for urgent or convenient care.
Yearly limit: The limit of how much money you pay for covered medical services, including copayments and coinsurance, each year. It’s also called out-of-pocket maximum.
*Review the provider directory at simplete.org for our in-network doctors and hospitals. With an HMO plan, you choose a primary doctor (or PCP) from our broad network. You’re not covered out of network unless it’s for emergency or urgent care.
With a POS plan, you still choose an in network PCP, but you have the freedom to go out of network. You save money by staying in-network, though.
1 Simplete (HMO)
2 Simplete 2 (HMO)
Tier 1 $0 $0 $4,000 $0 $25 $0 $40 $15 $15 $10 $50 $250 $110 $40 $200 $250 Days 1-8; $0 Days 9+ $0 Days 1-20; $196 Days 21-100 $0 $2 $15 $47 50% 33% Tier 1 Coverage Through the Gap
Tier 1 $28 $0 $4,950 $5 $25 $0 $40 $15 $10 $10 $50 $250 $110 $40 $200 $250 Days 1-8; $0 Days 9+ $0 Days 1-20; $196 Days 21-100 $0 $2 $15 $47 50% 33% Tier 1 Coverage Through the Gap
Tier 2 $20 $40 $0 $40 $20 20% 20% $150 $250 $110 $40 20% $250 Days 1-8; $0 Days 9+ $0 Days 1-20; $196 Days 21-100 $0 $2 $15 $47 50% 33% Tier 1 Coverage Through the Gap
3 Simplete 3 (HMO-POS)
Tier 1 $48 $0 $4,950 $5 $25 $0 $40 $15 $10 $10 $50 $250 $110 $40 $200 $250 Days 1-8; $0 Days 9+ $0 Days 1-20; $196 Days 21-100 $0 $2 $15 $47 50% 33% Tier 1 Coverage Through the Gap
Tier 2 $25 $40 $0 $40 $20 $25 20% $150 $250 $110 $40 25% $250 Days 1-8; $0 Days 9+ $0 Days 1-20; $196 Days 21-100 $0 $2 $15 $47 50% 33% Tier 1 Coverage Through the Gap
Out-of-Network $6,700 $50 $50 $0 $50 $50 $50 30% 30% $250 $110 $40 50% $600 Days 1-4; $0 Days 5-90 $100 Days 1-20; $200 Days 21-100 $0 $2 $15 $47 50% 33% Tier 1 Coverage Through the Gap
$95 $60 20% $300 Days 1-6; $0 Days 7+ $0 Days 1-20; $196 Days 21-100 N/A N/A N/A N/A
1-6;
1-20;
$0 $2
33% Tier
Coverage Through the Gap
$275 $275 Days 1-7; $0 Days 8+ $0 Days 1-20; $196 Days 21-100 $0 $2 $15 $47 50% 33% Tier 1 Coverage Through the Gap
7 HMO 20 Rx (HMO)† In-Network $125 $0 $4,000 $20 $40 $0 $40 $20 $10 $0 $5 $275 $110 $25 $275 $250 Days 1-7; $0 Days 8+ $0 Days 1-20; $196 Days 21-100 $0 $2 $15 $47 50% 33% Tier 1 Coverage Through the Gap
8 HMO Classic Rx (HMO) In-Network $0 $0 $8,300 $35 $50 $0 $40 $20 $40 20% $250 $400 $95 $60 25% $300 Days 1-6; $0 Days 7+ $0 Days 1-20; $196 Days 21-100 $100 $2 $15 $47 50% 31% Tier 1 Coverage Through the Gap
9 POS Basic (HMO-POS)† In-Network $23 $0 $6,700 $35 $50 $0 $40 $20 $40 $40 $40 $350 $95 $60 25% $450 Days 1-4; $0 Days 5+ $0 Days 1-20; $196 Days 21-100 N/A N/A N/A N/A N/A N/A N/A
Out-of-Network $11,300 $50 $65 $0 $50 $50 $50 $50 $50 $350 $95 $60 25% $600 Days 1-6; $0 Days 7-90 $100 Days 1-20; $200 Days 21-100 N/A N/A N/A N/A N/A N/A N/A
10 POS Basic Rx (HMO-POS) In-Network $53 $0 $6,700 $15 $50 $0 $40 $20 $40 $50 $50 $350 $95 $60 25% $450 Days 1-4; $0 Days 5+ $0 Days 1-20; $196 Days 21-100 $0 $2 $15 $47 50% 33% Tier 1 Coverage Through the Gap Out-of-Network $11,300 $50 $65 $0 $50 $50 $50 $50 $50 $350 $95 $60 25% $600 Days 1-6; $0 Days 7-90 $100 Days 1-20; $200 Days 21-100 $0 $2 $15 $47 50% 33% Tier 1 Coverage Through the Gap
11 POS 30 Rx (HMO-POS)† In-Network $105 $0 $5,500 $15 $45 $0 $20 $20 $40 $40 $40 $275 $110 $40 $325 $350 Days 1-5; $0 Days 6+ $0 Days 1-20; $196 Days 21-100 $0 $2 $15 $47 50% 33% Tier 1 Coverage Through the Gap Out-of-Network
In-Network
Key: This is a summary of commonly used benefits.
* Members on POS plans may pay more for preventive care out of network.
** The out-of-network yearly limit includes your combined costs for both in-network and out-of-network care.
*** Non-emergency cost-sharing may vary. Contact the plan for details.
# Emergency care available worldwide.
+ Also called convenient or walk-in care
^ You pay nothing for days 91 and beyond in network.
& Dollar amounts listed for inpatient hospital care and SNF are amounts you pay per day.
>> Not available on HMO Classic Rx.
Get
with a $360/year
a
$110 $40 $375 $375 Days 1-8; $0 Days 9-60; $200 Days 61-90 $200 Days 1-20; $400 Days 21-100 $0 $2 $15 $47 50% 33% Tier 1 Coverage Through the Gap
Get up to 30 hours of in-home support yearly (in one-hour increments).
Get help paying for dental services, like cleanings, X-rays and more, with coverage up to $2,000 a year. (Health Alliance HMO Basic and POS Basic have a $1,500 limit.)
Get one routine hearing exam for a $0 copay when you see a TruHearing® provider and lowered rates on up to two TruHearing hearing aids per year.
Get a 10% discount code for a wide variety of competitively priced over-the-counter (OTC) products with OTC4Me. You can order online or by phone, and all orders are shipped directly to you. Shipping is free on orders over $25.
Connect with your primary care provider or specialist over the phone or online without the inconvenience of going to the doctor’s office or sitting in a waiting room. Copayment may apply.
Talk to a board certified doctor or counselor by phone or secure video through hally.com, 24/7.
Get access to vision services beyond what Original Medicare covers, including a routine vision exam with an in-network provider. Plus, get a $150 >> allowance for eyewear.