2023 Simplete Handbook Retention.05

Welcome to Simplete® Medicare Advantage.

Simplete Medicare Advantage is a new approach to healthcare designed to deliver more benefits, more perks and fewer hassles. Every day, we’re working to make Simplete plans even better through our close provider partnerships and by listening to our members. Here are just a handful of advantages you get by being a Simplete plan member.

Have questions?

Contact Member Services: (877) 933-8475 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1 – September 30 simplete.org

Walk-In Hours: Weekdays 8:30 a.m. to 4:30 p.m. Office: 3301 Fields South Dr. Suite #105 Champaign, IL 61822

Your ID Card

You’ll receive your new member ID card from us by the beginning of your plan year (if you enrolled during the Annual Enrollment Period) or within a few weeks (if you enrolled at a different time). You’ll also receive an acknowledgment letter with your member number. You can use it as your temporary ID card until your actual ID card arrives.

You’ll use your member ID card at the doctor, hospital, pharmacy and other medical facilities. You’ll no longer need to use your red, white and blue Medicare card, but you should keep it in a safe place.

How to Access Care

Member Services

We’re here to help. Call us at the number on the back of your member ID card or contact us online at simplete.org with your questions. We’ll help you find the plan and doctors that make the most sense for your needs.

Primary Care Provider (PCP)

Find your PCP online using our Find Care tool at simplete.org/find-care. You can also call our care coordination team for assistance at (877) 933-8475 (TTY 711).

Nurse Advice Line

Get 24/7 answers to your health questions, like whether you need to set up an appointment or see a doctor right away.

Virtual Health Coverage

Get care when and where you need it through virtual health coverage.

• Telehealth Benefit

Connect with your primary care provider or specialist over the phone or online with the telehealth benefit. You can securely speak with your personal healthcare providers without having to leave the comfort of your home. Copayment may apply.

Access varies by provider. Speak with your provider to determine availability.

• Virtual Visits

Get care for common conditions like allergies, cold, flu and pink eye from anywhere you have phone or internet connection in the U.S. You can connect with a board certified doctor or counselor by phone or secure video through hally.com, 24 hours a day, 365 days a year – whether you’re at home, in the office or on the go.

Go to hally.com to log in and get started, or call Member Services at the number on the back of your member ID card for more information.

Urgent Care

All Simplete plans cover both in-network and out-of-network urgent care centers at the same copay. So if you experience an injury or illness anywhere in the world, your plan has you covered.

Emergency Services

If you’re having a medical emergency, you shouldn’t have to worry about your coverage. That’s why all Simplete plans include coverage for emergency services anywhere in the world.

Hally.com

While you’re logged in to hally.com, you can:

• Sign up for text alerts.

• Go paperless by opting in for secure e-Delivery of your plan materials.

• Know where to go for care depending on your symptoms.

• Pay your monthly premium using Premium Bill Pay and set up recurring payments.

• View past and current claims, authorizations and Explanations of Benefits.

• Find doctors, facilities and pharmacies covered by your plan.

• Check your spending.

Coverage While You Travel

When you travel 100 miles or more from home, Simplete Medicare Advantage members have access to Assist America®*, a global emergency service that’s ready to help if you have an immediate health need. Assist America can connect you to prompt, reliable medical attention, as well as some nonmedical services, as needed. Here are just some of the services that are included:

• Prescription assistance if you need medication or left your prescription behind.

• Medical referrals.

• Emergency medical evacuation.

• Lost luggage assistance.

• Interpreter and legal referrals.

All Assist America benefits apply on all of our Medicare Advantage plans, but when you’re out of network, our HMO plans cover only emergency and urgent care. Assist America will not pay you back for ambulance and other services you arrange on your own. In a life-threatening emergency, always call the ambulance right away. There is no added cost for the service itself, but there could still be a cost with any medical care. Other conditions and exclusions may apply.

Global Emergency Services

Reference Number: 01-AA-HAM-031003

Call Assist America’s Operations Center at:

• (800) 872-1414 (within the United States).

• (609) 986-1234 (outside the United States). Or email at: MedServices@AssistAmerica.com.

*Members may have additional costs related to travel services.

More Complete Benefits

Vision Coverage

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.

Acupuncture

Your plan is made with acupuncture coverage beyond what Original Medicare covers to give you more access to treatment when you need it.

• Treatment must be for headache, neck pain or lower back pain diagnoses.

• You don’t need prior authorization.

• You can choose any acupuncture provider.

• A per-visit copay may apply (varies by plan).

• You or your provider should submit claims using the information on the back of your ID card.

You get access to up to 15 covered visits for headache and neck pain. Coverage for lower back pain treatment includes 12 initial visits with eight additional visits if you’re showing improvement through treatment. Lower back pain visits are limited to 20 per year.

For more information, see your Evidence of Coverage or call the Member Services number on the back of your ID card.

Dental Coverage

Simplete Medicare Advantage members get $2,000 each year for services Original Medicare doesn’t cover. Your dentist can submit a claim for you directly to us using the claims information on the back of your member ID card. There’s no set network, so you can go to any dentist you choose.

Simplete plans include all Medicarecovered dental services but also offer non-Medicare-covered dental services as well. These additional benefits include but are not limited to:

• Oral exams.

• Cleanings.

• X-rays.

• Fluoride treatments.

• Fillings.

• Dentures.

• Denture adjustments and repairs.

• Crowns.

• Treatments for gum disease.

• Bridge work.

• Root canals and extractions.

You may have a copay or coinsurance for some dental services. Check your Summary of Benefits.

Tell your dentist you have a dental allowance through Medicare Advantage.

NOTE: You’ll be responsible for any cost above the maximum benefit limit. Refer to the Summary of Benefits for more informatio n about specific Simplete plan benefits and cost information.

Hearing Benefit

Through TruHearing®, you can get one routine hearing exam for a $0 copay and lowered rates on up to two TruHearing hearing aids per year when you see a TruHearing provider.

State-of-the-Art Technology

Experience the latest advances in hearing technology.

• Natural, lifelike sound in virtually all listening situations.

• Clearer speech, even in noisy environments.

• Ability to stream audio and phone calls directly to your ears from your smartphone

Personalized Care

Receive expert care from a team of helpful professionals.

• Guidance and assistance from a TruHearing consultant.

• Local, professional care from an accredited doctor in your area.

• A hearing exam, plus first year of follow-up provider visits for fitting and adjustments.

Help Along the Way Get started on the journey to better hearing with confidence.

• A worry-free purchase with a 60-day trial and three-year warranty.

• 80 free batteries per aid included with non-rechargeable models.

• Guides to help you adapt to your new hearing aids at TruHearing.com/GetStarted.

Call TruHearing to learn more and to schedule an appointment: (855) 205-5059 (TTY 711) Hours: 8 a.m. to 8 p.m., Monday – Friday

Drug Coverage

With a Simplete plan, Part D (prescription coverage) is included automatically. Plus, there are no pharmacy deductibles, and drug costs are kept low, thanks to our select network of pharmacy partners.

Understanding Drug Tiers

Covered drugs are categorized by tiers. The main difference between tiers is your out-of-pocket cost. The most commonly used drugs are considered Tier 1 and will be more affordable. The Simplete drug tiers are as follows:

The cost of a drug will depend on the tier it falls into and the pharmacy you use. Refer to your Summary of Benefits for more information about specific Simplete plan benefits and cost information.

Drug Reimbursement

All Simplete Medicare Advantage plans cover most self-administered drugs. However, there are some select cases where you may need to pay for these drugs upfront, then submit your receipt to get reimbursed through OptumRx.

Pharmacy Partnerships

Simplete plans streamline relationships with pharmacies to help lower costs for you by having a pharmacy network.

You must use an in-network pharmacy to get covered drugs unless it’s an emergency. For a list of in-network pharmacies, view our pharmacy directory at simplete.org/find-care.

Save with Simplete Medicare Advantage.

Simplete plans offer special savings programs to help you lower the cost of your medications further. Here are some of the ways you can save:

90-Day Supply Options

Limit your trips to the pharmacy with two convenient options. With our mail-order benefit, you can get a 90-day supply of your drugs delivered directly to you for two copays. If you prefer to get your drugs at a retail pharmacy, you can visit any in-network pharmacy and get a 90-day supply for three copays.

Medication Therapy Management

If you take multiple medications, this program can help you use them safely and effectively.

Extra Help

You might be able to get help to pay for your prescription drug premiums and costs through the Extra Help program.

To see if you qualify, call one of the following:

• (800) MEDICARE (800-633-4227), 24 hours a day, seven days a week (TTY 877-486-2048).

• The Social Security Administration at (800) 772-1213, 7 a.m. to 7 p.m., Monday through Friday (TTY 800-325-0778).

• The state’s Medicaid office.

Easy Pharmacy Benefits

Enjoy convenient pharmacy benefits, including:

Flu Shot

You can get the flu shot at no cost to you when you use any in-network doctor or pharmacy. If you get the shot at the doctor’s office, an office visit copay may apply.

Shingles Shot

The shingles shot falls under your pharmacy coverage. You can get the shot at any in-network pharmacy that offers the shot while paying only the Tier 3 cost-share amount.

Transferring Prescriptions Made Easy

You can transfer your prescriptions to a different in-network pharmacy. Many pharmacies let you transfer prescriptions over the phone, online or in person. Just make sure the pharmacy is still in network.

Lowest-Priced Option

If there’s a lower-priced deal at the pharmacy than what you’d pay through us, you’ll get the drugs for that lower price.

Medication Home Delivery

We’ve partnered with OptumRx to offer home delivery anywhere in the U.S.

• Pay less for your medication with a three-month supply.

• Get free standard shipping on medications delivered straight to your door.

• Request a free Deterra® bag to dispose of unwanted medication and help prevent misuse.

To sign up, visit OptumRx.com, use the OptumRx app or call the number on the back of your member ID card.

Drugs We Cover

All the drugs covered by Simplete plans are included in what we call a formulary. You can find the formulary online at simplete.org/pharmacy. There, you can also search for your prescription and estimate your costs for the year.

COSTS IN THE INITIAL

Catastrophic Coverage

This coverage begins when your out-of-pocket drug costs reach $7,400. At this stage, we pay for most of your drug costs for the rest of the year, while you pay the greater of the following:

• 5% of the cost.

• $4.15 for covered generic drugs (including brand-name drugs treated as generic).

• $10.35 for covered brand-name drugs.

Coverage Gap

This begins when the amount you pay plus the amount we pay for your prescription drugs reaches $4,660.

At this stage, you pay:

• 25% for covered generic drugs.

• 25% for covered brand-name drugs.

Initial Coverage

You start in this stage at the beginning of the year and pay your applicable copays/coinsurance until you reach the coverage gap.

Coverage Through the Gap

If your total prescription spend adds up to $4,660, you’ll reach the coverage gap. With your Simplete plan, you’ll continue to pay your copay for Tier 1 medications until your out-of-pocket expenses reach $7,400.

Simplete is powered by Health Alliance™ – a Medicare Advantage Organization with a Medicare contract. Enrollment in Simplete depends on contract renewal. Other pharmacies or providers are available in our network.

Caring About You

Feeling like just a number in a system? That was the old way. Now there’s a new way. Simplete plans include wellness perks and a care coordination team to help you live a healthy lifestyle.

Care Coordination and Health Coaching Team

What Truly Sets Us Apart

It’s time to focus more on preventing illness and injury. With our care coordination and health coaching team, you receive personalized care that guides you toward a healthy lifestyle.

This includes:

• Setting and reaching health and wellness goals.

• Understanding and managing health issues, like diabetes and asthma.

• Coordinating care for complicated health conditions.

• Optimizing health benefits to save money.

• Helping prevent illness and hospital stays.

• Finding helpful resources.

How It Works

Think of our care coordination and health coaching team as an extension of your doctor’s office. We have a dedicated team of social workers, dietitians, pharmacists and health coaches – all working together on your behalf. Here are some of the ways we help:

• After being diagnosed with diabetes, it can be very confusing to manage new medications, blood sugar levels and a new diet. We help remove confusion and keep things on track.

• After hip replacement surgery, there will be medications to manage and physical therapy to attend. The care team can help arrange these services before you even leave the hospital.

• Nurse practitioners can provide in-home visits to ensure you have a safe living environment, then connect you with community resources to help improve your environment as needed.

• At any time, our team can help you with making healthy lifestyle changes, including eating better, working out and more.

Member

Care Manager

Primar y Care Provider

Core Team

Extended Team

Medical Director Pharmacist

Social Worker Care Management Representative Dietitian

Perks, Programs and More

With a Simplete plan, you’ll receive special perks you can use every day. We want to help you live a happy, healthy lifestyle, so we offer plenty of perks and incentive programs to help.

Preventive Care

At no additional cost to you, Simplete plans cover many preventive services, including:

• Annual wellness visits.

• Routine cancer screenings (including mammograms and colonoscopies).

• Cardiovascular disease risk-reduction visits.

• Flu shots.

• Bone mass measurements.

• Depression, diabetes and HIV screenings.

• Hepatitis B and pneumococcal shots.

• Medical nutrition therapy.

• Obesity screening and therapy.

• Screening and counseling to reduce alcohol misuse.

• Screening for sexually transmitted infections (STIs) and counseling to prevent STIs.

• Counseling to stop smoking or tobacco use.

• “Welcome to Medicare” preventive visit (one time).

Be Fit

Get paid back for a variety of fitness activities. You choose how you want to work out, and we pay you back up to $360 a year. * Activities include the following and more:

• Fitness class fees.

• Gym memberships.

• Online fitness subscriptions.

• Weight loss subscriptions.

• Ski memberships.

• Rowing.

• Golf.

• Bowling.

• Tennis.

• Pickleball.

• Recreational league fees.

• Pool exercise classes.

• 5K/10K race fees.

• Personal training.

If your fees are more than $360 a year, you pay the difference. If they’re less, we pay you back the amount you paid. Be Fit doesn’t cover fitness trackers or personal equipment.

* You also have access to a membership at Riverside Health Fitness Center for no extra cost. You can use it in place of the reimbursement, but you can’t use both benefits.

Scan the QR code for the reimbursement form.

HealthAlliance.org/Medicare/Be-Fit-Form

Wellness Rewards

Take steps toward better health while working your way toward a $50 gift card through our claims-based Wellness Rewards program. Become eligible for your reward by completing certain wellness activities. There’s no need to submit any extra paperwork. Learn more at simplete.org/perks.

Quit For Life®

Quitting tobacco is one of the biggest positive impacts you can make on your health. That’s why we offer the Quit For Life program – the nation’s leading tobacco-cessation program. This service helps you quit for good by using:

• One-on-one coaching from a quit coach.

• A personalized quit plan.

• Helpful tools, like Text2Quit® .

• Web Coach®, an online learning and support community.

OTC4Me

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.

whiskerDocs

Connect to 24/7 help from veterinary technicians with whiskerDocs. You can call, chat or email with questions about your animals’ health or well-being. The service helps with cats, dogs, birds, reptiles and pocket pets (like rabbits or hamsters). About 60% of issues are taken care of over the phone without a visit to the veterinarian. Learn more at simplete.org/perks.

Companion Benefit

Get up to 30 hours of in-home support yearly through the Papa Pal program. This service gives you access to a friendly companion who can help you with a variety of tasks. Plus, they can be a fun person to chat with. And they can go with you to places like a library, park, doctor’s office, pharmacy and more.

Services include:

• Companionship (like playing games, eating lunch or having a conversation).

• Transportation.

• Technical support (like setting up streaming platforms or teaching you how to make a video call).

• Light help around the house.

• Light exercise.

• Grocery shopping.

• Help with your pet.

Services are typically provided in one-hour increments.

10 Frequently Asked Questions

1. How and why should I reach out to Member Services?

• Call the Member Services number on the back of your member ID card. You should have your member number ready. You’ll be prompted to make selections based on your type of question.

• Call for answers to questions about your plan, including topics like eligibility, premiums, claims, prescriptions, authorizations, letters and more.

2. Should I expect to receive a monthly premium statement for my plan?

Yes, in most cases. There are a few instances, however, in which you won’t receive a monthly statement:

• If you set up Social Security withdrawal.

• If you set up recurring payments using our mail-in form or online at simplete.org/pay.

• If your policy was terminated and the account has a $0 balance.

3. What’s the main difference between copay and coinsurance?

A copay is a set dollar amount you pay for a given service. For example, you might pay a set amount of $10 for a doctor’s appointment or when you fill a prescription.

A coinsurance is a set percentage you’re responsible for paying. For example, a 20% coinsurance means your plan pays 80%, and you pay 20%.

4. What steps can I take to resolve a claims issue (if I’ve been billed for charges by a doctor/facility that I thought was covered by my plan)?

Always call Member Services first for claims issues. We can help you figure out if the claim has been submitted to us properly and if it has been paid partially or in full, and we can direct you on next steps to make sure your questions are resolved as soon as possible.

5. How can I check if a doctor or facility is in network?

• Call Member Services at the number on the back of your member ID card to check if a doctor or facility is in network.

• Use our Find Care search at simplete.org/find-care to see if your doctor or facility is in network.

• Log in at simplete.org or hally.com to review your doctor and pharmacy directory.

6. How can I get approval for a prescription that requires prior authorization?

• Have your doctor’s office contact our Pharmacy department at (800) 851-3379, option 4, to start the authorization over the phone.

• You or your appointed representative (declared in an Appointment of Representative form) can start the authorization over the phone.

• The doctor’s office may also submit a prior authorization form by fax to (217) 902-9798.

7. How can I check if there are any benefit changes to my plan for the new plan year (starting January 1)?

Benefits and other aspects of a plan are likely to change to some degree (annually) even if you keep the same plan. Below are some of the ways you can identify the changes. These materials can be found online at simplete.org/benefits, on hally.com and are also mailed to you.

• Review your Evidence of Coverage (EOC).

• Review your Annual Notice of Change (ANOC). The ANOC for your plan is mailed every September.

• Call the Member Services number on the back of your member ID card. We can help you with any benefit change questions you might have for your plan.

8. How can I make a premium payment?

• Call the Member Services number on the back of your member ID card and choose “Make a Payment” using our automated system.

• Mail a check with your statement stub (or provide credit card info on the back of the stub for a one-time payment).

• Submit an automatic withdrawal form to us and have the payment taken from your credit card or bank account via automated clearing house.

• Pay your premium via Social Security withdrawal.

• Make a one-time premium payment (or set up recurring payments) online by logging in to simplete.org/pay.

9. What is the difference between a deductible and an out-of-pocket maximum? A deductible is a designated amount members pay toward medical or pharmacy

expenses before their copay or coinsurance kicks in. Simplete Medicare Advantage plans, including yours, don’t have deductibles.

The out-of-pocket maximum (OOPM) is the total amount you pay for healthcare expenses in a given plan year before we start to cover 100% of eligible expenses. This is also called your yearly limit. You no longer pay copayments or coinsurance, just your monthly premium. In-network services (also referred to as Tier 1 and Tier 2) both apply to the in-network OOPM. Note that if you receive services that are non-covered or use out-of-network providers (referred to as Tier 3), you may be required to cover costs above the OOPM. There is no cap on the amount that you may have to pay for non-covered services or using out-of-network providers.

10. How do I register online at hally.com, and why should I sign up?

To create an account, go to hally.com. While you’re logged in to hally.com, you can:

• Sign up for text alerts.

• Go paperless by opting in for secure e-Delivery of your plan materials.

• Know where to go for care depending on your symptoms.

• Pay your monthly premium using Premium Bill Pay and set up recurring payments.

• View past and current claims, authorizations and Explanations of Benefits.

• Find doctors, facilities and pharmacies covered by your plan.

• Check your spending.

Common Healthcare Terms

Appointed Representative:

This is someone who can represent you in a Medicare matter (such as an appeal or grievance). To appoint someone, you need to fill out an Appointment of Representative (AOR) form CMS-1696, available from us and the Centers for Medicare & Medicaid Services.

Coverage period:

The stretch of time your plan covers you, usually January 1 to December 31 each year.

Deductible:

The amount you pay before your benefits kick in. Some plans have separate medical and pharmacy deductibles. Your plan doesn’t have a deductible.

Formulary:

A list of common medicines grouped by drug class (how they work) or by the medical problem they treat. We generally only cover drugs listed in the formulary.

Generic drug:

A drug that has the same active ingredients as a brand-name drug but costs less.

Network:

The doctors, clinics and hospitals a health plan works with to provide discounted services to members.

Prior authorization:

A review process your doctor requests in order to see if your plan will cover certain drugs or services before you get them. Think of this as a second opinion.

Preventive care:

Practicing prevention helps find and treat medical problems before they become serious or life-threatening. Preventive care includes routine exams, lab tests, screenings and vaccines.

Provider:

A doctor, nurse, physician assistant, etc., you see for healthcare. You choose a primary care provider (PCP) as the main provider to oversee your care and refer you to specialists.

Urgent care/walk-in clinic:

If you need care now, but it’s not an emergency and you can’t get into your PCP, you can go to an urgent (or convenient) care clinic.

You can find other common healthcare terms in your 2023 Key Medicare Benefits guide.

Scan the QR code to learn more about your plan.

Member Terms

Rights and Responsibilities

As a member, you have several rights you’re entitled to, such as receiving reasonable access to healthcare and having candid discussions about appropriate or medically necessary treatment options for your conditions.

You also have certain responsibilities as a member, such as reading and understanding your Evidence of Coverage (EOC), as well as any attached riders, rules or amendments.

For a complete list of rights and responsibilities, visit simplete.org.

Making Changes to Your Plan

Switching Plans

You can switch plans during the Annual Enrollment Period (AEP). The AEP is determined by the Centers for Medicare & Medicaid Services (CMS). Typically, this is one of the few times each year you can make changes, unless you meet special exceptions.

The AEP is October 15 through December 7 each year with plan coverage starting January 1. Please contact Member Services if you have questions. We may have a different plan available in your area that could be a better fit for your current situation.

Disenrollment

If you decide to disenroll, this means you’re ending your membership. Disenrollment can be voluntary (your choice) or involuntary (not your choice). If you decide you want to leave your plan, you can do this for any reason. However, there are limits to when you may leave, how often you can make changes and what type of plan you can join after you leave.

Call Member Services for more information on voluntary and involuntary disenrollment.

Plan Protections

If you ever have an issue with your plan, we make it easy to reach out. If you have any grievances or want to appeal a decision, just call Member Services at the number on the back of your member ID card and someone will help you with the filing process.

Grievance

File this complaint about the plan if you feel you’ve had poor quality of care or customer service. Call us to get started within 60 days or as soon as possible.

Appeal

File this to disagree with the plan’s decision to deny a request to cover healthcare services or pay for services received. File in writing within 60 days or as soon as possible.