Powered by Health AllianceTM
Helpful Terms Ambulance: What you pay for an ambulance ride in an emergency.
Outpatient surgery: What you pay for an outpatient procedure.
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%).
Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare.
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.
Medicare Advantage vs. Medicare Supplement Get more out of Medicare with Medicare Advantage.
Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium.
Medicare Advantage
2022 BIG-PICTURE GUIDE
Primary care provider (PCP) visit: The amount you pay at the doctor’s office when you visit your innetwork primary care doctor.*
Medicare Supplement
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.
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.*
It’s simple. It’s complete. 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 complete plan information.
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.
No medical underwriting.
Health Alliance™ Medicare complies with applicable Federal civil rights laws and does not discriminate on the basis
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.
Who pays in what order: Original Medicare, health plan, you.
Not age- or tobacco-rated.
Age- and tobacco-rated.
of race, color, national origin, age, disability or sex. Spanish: ATENCIÓN: Si habla español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted. Llame (800) 965-4022 (TTY 711). Chinese: 注意：如果你講中 文，語言協助服務，免費的，都可以給你。呼叫 (800) 965-4022 (TTY 711).
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.
Simplete is powered by Health Alliance Medicare - a Medicare Advantage Organization with a Medicare contract. Enrollment in Simplete depends on contract renewal. Other pharmacies/providers are available in our network. Out-of-network/non-contracted providers are under no obligation to treat Simplete members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
MDMBSI22-ILNRIVfoldguide-0621 • H1463_22_98523_M
Powered by Health AllianceTM
Helpful Terms Ambulance: What you pay for an ambulance ride in an emergency.
Outpatient surgery: What you pay for an outpatient procedure.
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%).
Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare.
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.
Medicare Advantage vs. Medicare Supplement Get more out of Medicare with Medicare Advantage.
Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium.
Medicare Advantage
2022 BIG-PICTURE GUIDE
Primary care provider (PCP) visit: The amount you pay at the doctor’s office when you visit your innetwork primary care doctor.*
Medicare Supplement
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.
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.*
It’s simple. It’s complete. 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 complete plan information.
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.
No medical underwriting.
Health Alliance™ Medicare complies with applicable Federal civil rights laws and does not discriminate on the basis
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.
Who pays in what order: Original Medicare, health plan, you.
Not age- or tobacco-rated.
Age- and tobacco-rated.
of race, color, national origin, age, disability or sex. Spanish: ATENCIÓN: Si habla español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted. Llame (800) 965-4022 (TTY 711). Chinese: 注意：如果你講中 文，語言協助服務，免費的，都可以給你。呼叫 (800) 965-4022 (TTY 711).
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.
Simplete is powered by Health Alliance Medicare - a Medicare Advantage Organization with a Medicare contract. Enrollment in Simplete depends on contract renewal. Other pharmacies/providers are available in our network. Out-of-network/non-contracted providers are under no obligation to treat Simplete members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
MDMBSI22-ILNRIVfoldguide-0621 • H1463_22_98523_M
Powered by Health AllianceTM
Helpful Terms Ambulance: What you pay for an ambulance ride in an emergency.
Outpatient surgery: What you pay for an outpatient procedure.
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%).
Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare.
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.
Medicare Advantage vs. Medicare Supplement Get more out of Medicare with Medicare Advantage.
Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium.
Medicare Advantage
2022 BIG-PICTURE GUIDE
Primary care provider (PCP) visit: The amount you pay at the doctor’s office when you visit your innetwork primary care doctor.*
Medicare Supplement
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.
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.*
It’s simple. It’s complete. 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 complete plan information.
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.
No medical underwriting.
Health Alliance™ Medicare complies with applicable Federal civil rights laws and does not discriminate on the basis
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.
Who pays in what order: Original Medicare, health plan, you.
Not age- or tobacco-rated.
Age- and tobacco-rated.
of race, color, national origin, age, disability or sex. Spanish: ATENCIÓN: Si habla español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted. Llame (800) 965-4022 (TTY 711). Chinese: 注意：如果你講中 文，語言協助服務，免費的，都可以給你。呼叫 (800) 965-4022 (TTY 711).
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.
Simplete is powered by Health Alliance Medicare - a Medicare Advantage Organization with a Medicare contract. Enrollment in Simplete depends on contract renewal. Other pharmacies/providers are available in our network. Out-of-network/non-contracted providers are under no obligation to treat Simplete members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
MDMBSI22-ILNRIVfoldguide-0621 • H1463_22_98523_M
Plan†
1
1
2
3
4
5
Plan Costs
Office Visits
Diagnostic Services
Emergency Services
Hospital Services
$220
$90
$10
$60
$220
20%
20%
20%
$15
$10
$10
$40
$20
20%
$0
$60
$50
Chiropractic Lab
$0
$0
$4,750
$0
$10
$0
$10
$15
$10
$10
$50
$0
$4,950
$5
$10
$0
$10
$15
$10
$4,950
$25
$40
$0
$40
$20
$4,950
$5
$10
$0
$10
Tier 2
$4,950
$25
$40
$0
Out-of-Network
$6,700
$50
$60
Tier 1 Tier 2
3 Simplete Riverside 3 (HMO-
$50
Virtual Physical Visit Therapy
Simplete Riverside 1 (HMO)* Tier 1
2 Simplete Riverside 2 (HMO)
Urgent Care+
Yearly Limit PCP Visit Specialist (does not include Visit pharmacy)
Premium
Tier 1
$70
$0
2021 BIG PICTURE GUIDE
Ambulance» Emergency Care***
Medical Deductible
Network
X-Ray
CT/MRI
Initial Rx Coverage (for 30-day supply)
Outpatient Inpatient Hospital Care^ Hospital Care (including services received)
Skilled Nursing Facility (noncustodial care based on medical necessity)
Rx Deductible
1
2
3
4
$40
$100
$225/Day (1-8), $0/Day (9+)
$0/Day (1-20), $188/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$90
$40
$100
$225/Day (1-8), $0/Day (9+), Non-Medicare covered stays follow Tier 2 benefit
$0/Day (1-20), $188/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$220
$90
$40
20%
$465/Day (1-4), $0/Day (5+)
$0/Day (1-20), $188/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$60
$220
$90
$40
$100
$225/Day (1-8), $0/Day (9+), Non-Medicare covered stays follow Tier 2 benefit
$0/Day (1-20), $188/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
20%
20%
$220
$90
$40
25%
$465/Day (1-4), $0/Day (5+)
$0/Day (1-20), $188/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
25%
25%
25%
$220
$90
$40
50%
$600/Day (1-4), $0/Day (5-90)
$100/Day (1-20), $200/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
POS)
Rx Cost by Tier
Rx Gap Coverage 5
4 HMO Basic Rx (HMO)
In-Network
$33
$0
$6,700
$5
$45
$0
$40
$20
$20
20%
$150
$275
$90
$65
20%
$300/Day (1-6), $0/Day (7+)
$0/Day (1-20), $188/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
5 HMO 40 RX (HMO)
In-Network
$75
$0
$4,700
$10
$40
$0
$40
$20
$15
$10
$150
$275
$90
$40
$275
$275/Day (1-7), $0/Day (8+)
$0/Day (1-20), $188/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
6 HMO 20 RX (HMO)
In-Network
$125
$0
$4,000
$20
$40
$0
$40
$20
$10
$0
$5
$275
$90
$25
$275
$250/Day (1-7), $0/Day (8+)
$0/Day (1-20), $188/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
7 POS Basic Rx (HMO-POS)
In-Network
$53
$0
$6,700
$15
$50
$0
$40
$20
$40
$50
$50
$350
$90
$65
25%
$450/Day (1-4), $0/Day (5+)
$0/Day (1-20), $188/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$11,300
$50
$65
$0
$50
$50
$50
$50
$50
$350
$90
$65
25%
$600/Day (1-6), $0/Day (7-90)
$100/Day (1-20), $200/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$5,500
$15
$45
$0
$20
$20
$40
$40
$40
$275
$90
$40
$325
$350/Day (1-5), $0/Day (6+)
$0/Day (1-20), $188/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$11,300
$50
$50
$0
$50
$50
$50
$50
$50
$275
$90
$40
$375
$375/Day (1-8), $0/Day (9-60), $200/Day (61-90)
$200/Day (1 - 20), $400/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$4,500
$20
$30
$0
$20
$20
$0
$0
$0
$275
$90
$30
$275
$250/Day (1-8), $0/Day (9+)
$0/Day (1-20), $188/Day (21 - 100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$5,750
$40
$40
$0
$30
$45
$30
$30
$30
$275
$90
$30
$325
25%
$85/Day (1-20), $225/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
Out-of-Network
8 POS 30 RX (HMO-POS)
In-Network
$105
$0
Out-of-Network
9 POS 10 RX (HMO-POS)
In-Network
$165
Out-of-Network
$0
*Only available in Iroquois and Kankakee counties.
Key: This is a summary of commonly used benefits. † Members on POS plans may pay more for preventive care out of network.
IN means in-network, and OON means out-of-network.
»N on-emergency cost-sharing may vary. Contact the plan for details.
The out-of-network yearly limit includes your combined costs for both in-network and out-of-network care.
*** Emergency care available worldwide. + Also called convenient or walk-in care ^ You pay nothing for days 91 and beyond in network. #M embers may have costs related to travel services.
Simplete Perks: A Closer Look
Contact us.
Be Fit
Dental Coverage
OTC4Me
Vision Coverage
Hearing Benefit
Get fit with a $360/year reimbursement on a variety of fitness activities.
Get help paying for dental services, like cleanings, X-rays and more, with coverage up to $1,500 a 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.
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.
Get one routine hearing exam for a $45 copay when you see a TruHearing® provider and lowered rates on up to two TruHearing hearing aids per year.
(877) 933-8481 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1 – September 30 simplete.org.
Powered by Health AllianceTM
Helpful Terms Ambulance: What you pay for an ambulance ride in an emergency.
Outpatient surgery: What you pay for an outpatient procedure.
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%).
Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare.
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.
Medicare Advantage vs. Medicare Supplement Get more out of Medicare with Medicare Advantage.
Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium.
Medicare Advantage
2022 BIG-PICTURE GUIDE
Primary care provider (PCP) visit: The amount you pay at the doctor’s office when you visit your innetwork primary care doctor.*
Medicare Supplement
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.
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.*
It’s simple. It’s complete. 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 complete plan information.
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.
No medical underwriting.
Health Alliance™ Medicare complies with applicable Federal civil rights laws and does not discriminate on the basis
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.
Who pays in what order: Original Medicare, health plan, you.
Not age- or tobacco-rated.
Age- and tobacco-rated.
of race, color, national origin, age, disability or sex. Spanish: ATENCIÓN: Si habla español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted. Llame (800) 965-4022 (TTY 711). Chinese: 注意：如果你講中 文，語言協助服務，免費的，都可以給你。呼叫 (800) 965-4022 (TTY 711).
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.
Simplete is powered by Health Alliance Medicare - a Medicare Advantage Organization with a Medicare contract. Enrollment in Simplete depends on contract renewal. Other pharmacies/providers are available in our network. Out-of-network/non-contracted providers are under no obligation to treat Simplete members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
MDMBSI22-ILNRIVfoldguide-0621 • H1463_22_98523_M