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), preauthorization 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
2021 BIG-PICTURE GUIDE
Primary care provider (PCP) visit: The amount you pay at the doctor’s office when you visit your in-network 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 SimpleteTM
Urgent care: The amount you pay for urgent or convenient care.
benefits, perks and common costs. If you have a specific question about your premiums or coverage, refer to the booklet for
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.
complete plan information. 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 1-800-965-4022 (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 1-800-965-4022 (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.
MDMKSI21-LOCfoldguide-0420 • H1463_21_85998_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), preauthorization 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
2021 BIG-PICTURE GUIDE
Primary care provider (PCP) visit: The amount you pay at the doctor’s office when you visit your in-network 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 SimpleteTM
Urgent care: The amount you pay for urgent or convenient care.
benefits, perks and common costs. If you have a specific question about your premiums or coverage, refer to the booklet for
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.
complete plan information. 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 1-800-965-4022 (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 1-800-965-4022 (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.
MDMKSI21-LOCfoldguide-0420 • H1463_21_85998_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), preauthorization 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
2021 BIG-PICTURE GUIDE
Primary care provider (PCP) visit: The amount you pay at the doctor’s office when you visit your in-network 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 SimpleteTM
Urgent care: The amount you pay for urgent or convenient care.
benefits, perks and common costs. If you have a specific question about your premiums or coverage, refer to the booklet for
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.
complete plan information. 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 1-800-965-4022 (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 1-800-965-4022 (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.
MDMKSI21-LOCfoldguide-0420 • H1463_21_85998_M
Plan†
1
2
3
4
Plan Costs
Office Visits
Diagnostic Services
Emergency Services
Network
Premium
Medical Deductible
Yearly Limit PCP Visit (does not include pharmacy)
Specialist Visit
Virtual Visit
Physical Therapy
Chiropractic Lab
X-Ray
CT/MRI
5
2021 BIG PICTURE GUIDE
Ambulance»
Emergency Care***
Urgent Care+
Hospital Services
Outpatient Inpatient Hospital Care^ Hospital Care (including services received)
Skilled Nursing Facility (noncustodial care based on medical necessity)
1
2
3
4
5
Rx Cost by Tier
1
Simplete 1 (HMO)
Tier 1
$0
$0
$4,000
$0
$25
$0
$40
$15
$10
$10
$50
$220
$90
$40
$100
$200/Day (1-8), $0/Day (9+)
$0/Day (1-20), $178 (Days 21-100)
$2
$15
$47
50%
33%
2
Simplete 2 (HMO)
Tier 1
$28
$0
$4,500
$5
$25
$0
$40
$15
$10
$10
$50
$220
$90
$40
$100
$0/Day (1-20), $178 (Days 21-100)
$2
$15
$47
50%
33%
$4,500
$20
$40
$0
$40
$20
20%
20%
$150
$220
$90
$40
20%
$200/Day (1-8), $0 (Days 9+), Non- Medicare covered stays follow Tier 2 benefit
$0/Day (1-20), $178 (Days 21-100)
$2
$15
$47
50%
33%
$0/Day (1-20), $178 (Days 21-100)
$2
$15
$47
50%
33%
$0/Day (1-20), $178 (Days 21-100)
$2
$15
$47
50%
33%
$100/Day (1-20), $200 (Days 21-100)
$2
$15
$47
50%
33%
Tier 2
$250/Day (1-8), $0 (Days 9+)
3
Simplete 3 (HMO-POS)
Tier 1
$48
$0
Tier 2 Out-ofNetwork
$4,500
$5
$25
$0
$40
$15
$10
$10
$50
$220
$90
$40
$100
$4,500
$25
$40
$0
$40
$20
$25
20%
$150
$220
$90
$40
25%
$200/Day (1-8), $0 (Days 9+), Non- Medicare covered stays follow Tier 2 benefit
50%
$250/Day (1-8), $0 (Days 9+)
$6,700
$50
$50
$0
$50
$50
$50
30%
30%
$220
$90
$40
$600/Day (1-4), $0 (Days 5-90)
Simplete Perks: A Closer Look
Virtual Health Coverage
Be Fit
House Calls
Vision Coverage
+ Also called convenient or walk-in care The OON yearly limit includes your combined costs for both in-network and out-of-network care.
Get fit with a $360/year reimbursement at the fitness center of your choice.
Member magazine to share healthy tips and plan details.
Get access to vision services beyond what Original Medicare covers.
^ You pay nothing for days 91 and beyond in-network.
Nurse Advice Line
Care Coordination
Wellness Rewards
Get 24/7 answers to your health questions.
† Members on POS plans may pay more for preventive care out-of-network.
# Members may have costs related to travel services.
$50 gift card for taking specific healthy steps outlined at simplete.org/perks.
Preventive Care
Connect to a team of providers who work with your doctor to make sure you have the resources you need to stay healthy or work through your medical issues.
Key: This is a summary of commonly used benefits. IN means in-network, and OON means out-of-network.
» Non-emergency cost-sharing may vary. Contact the plan for details.
*** Emergency care available worldwide.
Focus on prevention with coverage for a yearly wellness visit, routine screenings, flu shot and more.
Assist America Get expert medical help when you’re 100 miles or more from home.
Talk to a board certified doctor or counselor by phone or secure video through the Hally™ app, 24/7.
Quit For Life® Dental Coverage
Get personalized help to end your tobacco use.
Get help paying for dental services, like cleanings, X-rays and more, with coverage up to $200 a year. (Some plans may have higher coverage).
Hearing Benefit 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.
Contact us (877) 634-3390 (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), preauthorization 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
2021 BIG-PICTURE GUIDE
Primary care provider (PCP) visit: The amount you pay at the doctor’s office when you visit your in-network 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 SimpleteTM
Urgent care: The amount you pay for urgent or convenient care.
benefits, perks and common costs. If you have a specific question about your premiums or coverage, refer to the booklet for
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.
complete plan information. 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 1-800-965-4022 (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 1-800-965-4022 (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.
MDMKSI21-LOCfoldguide-0420 • H1463_21_85998_M