2023 CRM Simplete Benefits Guide

Meet Simplete Medicare Advantage.

The simpler way to complete Medicare coverage.

Medicare can be complex. That’s why we set out to create something simpler. We listened to feedback from patients and local healthcare providers who know best how to serve the needs of the community. Through their guidance and partnership, we’ve been able to achieve a common goal: a Medicare plan that delivers an easier, more affordable healthcare experience.

Simplete

By creating better collaboration between providers and the insurance company, we’ve been able to reduce the red tape, lower costs and provide more benefits. Now you can enjoy a simpler, more complete

experience.

isn’t just

plan – it’s a whole new approach to healthcare.

Simplete Medicare Advantage at a Glance

Our Simplete plan includes:

• $0 monthly premium.

• No medical or pharmacy deductible.

• Free primary care visits, and dental and vision exams.

• Over-the-counter discount program.

• $2 Tier 1 generics.

• Air ambulance coverage.

Not sure if this Simplete plan is right for you?

Call us at (877) 561-8307 (TTY 711) or contact us online at simplete.org/medicare with your questions. We’ll help you find the plan and providers that make the most sense for your needs.

Find an overview of your plan options and benefits in our 2023 Big-Picture Guide.

COSTS AT A GLANCE

SIMPLETE RICHLAND 1 (HMO)

Pay for what you actually use.

Wasting money on coverage you don’t use? That was the old way. Now there’s a new way.

Simplete Medicare Advantage gives you perks you can use every day.

Simple and Complete

Frustrated by the confusing layers of Medicare benefits? That was the old way. Now there’s a new way. Simplete Medicare Advantage offers complete care and added perks in one simple package.

Medicare Advantage vs. Medicare Supplement

All the different types of Medicare plans can be overwhelming, which is why we decided to focus on Medicare Advantage.

Medicare Advantage allows us to streamline the healthcare services you need most (doctor appointments, hospital visits, prescriptions, hearing, dental and vision benefits) all in one plan. However, Medicare Advantage may not be for everyone. Here is a look at the main differences between Medicare Supplement and Medicare Advantage:

MEDICARE SUPPLEMENT

How It Works

Perks

Pays for Medicare-eligible services after Original Medicare (Parts A and B) pays its share.

No included perks.

Drug Coverage

Monthly Premium

Still need to get separate prescription coverage (Part D).

The monthly premiums are higher, but you’ll likely not pay out-of-pocket costs.

MEDICARE ADVANTAGE

Pays for your medical expenses in place of Original Medicare.

Adds perks, like dental, vision, hearing and wellness.

Covers services you need (after Parts A and B), including prescription coverage (Part D).

Medicare Advantage has lower monthly premiums. Our Simplete plan has a $0 premium.

Age and Tobacco Use

Doctors

Age and tobacco use will affect monthly premium.

Flexibility to see any doctor who accepts Original Medicare.

Age and tobacco use won’t affect monthly premium.

Must choose in-network primary care providers for care or the ability to see OON providers at an additional cost.

All members enrolling in Medicare Advantage must start with enrolling in Original Medicare, Parts A (hospital) and B (medical/outpatient care). OON = out-of-network care.

To be eligible for Simplete Medicare Advantage, you must live in the service area and must continue to pay your Medicare Part B premium if not otherwise paid for by Social Security or another third party.

In-Network Providers

The Simplete network is made of leading community providers you know and trust from Carle Richland Memorial Hospital. By partnering with Carle Richland Memorial Hospital, we help reduce healthcare costs and put more control back into the hands of doctors.

You can find a list of some of the providers, clinics and hospitals that are in network in the provider flier. For a full list, go to simplete.org/medicare.

Provider Promise

If there is no in-network provider who can treat your condition, we’ll work to find a provider who can – and cover it at the in-network cost.

Filling the Gaps

Medicare not including dental, hearing or vision? That was the old way. Now there’s a new way. Simplete Medicare Advantage includes these benefits and more.

More Complete Benefits

Acupuncture

If you have a qualifying diagnosis, your Simplete coverage includes acupuncture treatments. Qualifying diagnoses include headache, neck pain and lower back pain.

Comprehensive Dental

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 Medicare-covered dental services but also offer non-Medicarecovered 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.

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.

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.

Coverage Wherever You Go

Get coverage from home:

• Virtual health coverage.

• Nurse Advice Line.

Get coverage when traveling:

• Urgent and emergency care worldwide.

• No matter what urgent care/ emergency department you visit, it won’t cost more than it would in network. Additional medical and non-medical benefits are provided by Assist America®.

Air ambulance is covered at a $220 copay.

Simplete Drug Coverage

Many Medicare options don’t include prescription drug coverage (also known as Part D). It must be purchased and managed separately. Also, if you forget to enroll in Part D, you may receive a late penalty.

With Simplete Medicare Advantage, Part D (prescription coverage) is included automatically. Plus, there are no pharmacy deductibles, and drug costs are kept low, thanks to our network of pharmacy partners. Lower cost. Less hassle.

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 generally cost less. The Simplete drug tiers are as follows:

Tier 1 - Preferred Generic

Tier 2 - Generic

Tier 3 - Preferred Brand Tier 4 - Non-Preferred Drug

Tier 5 - Specialty Tier

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

Prescriptions for Less

Paying for a separate prescription plan? That was the old way. Now there’s a new way. Simplete Medicare Advantage includes prescription coverage – and for less, thanks to our pharmacy partnerships.

Pharmacy Partnerships

Simplete Medicare Advantage streamlines 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/medicare, or request a copy using the card in the back of this guide.

Save with Simplete Medicare Advantage.

Every opportunity to save money is important, especially when it comes to prescriptions. That’s why Simplete Medicare Advantage offers special savings programs to help you lower the cost of your medications. Here are some of the ways you can save with Simplete Medicare Advantage:

No Pharmacy Deductible – The Simplete Richland 1 plan begins with full benefits immediately. There is no pharmacy deductible you have to meet first.

90-Day Supply Savings – 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, our complimentary Medication Therapy Management Service helps you use them safely and effectively.

Financial Assistance – You may be eligible to receive financial assistance for your prescriptions 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 Medicaid office for your state.

Drugs We Cover

All the drugs covered by Simplete Medicare Advantage are included in what we call a formulary. The formulary packet is included with this booklet. You can also find the formulary online to search for your prescription and estimate your costs for the year at simplete.org/medicare.

COSTS IN THE INITIAL COVERAGE PERIOD

30-DAY

COST BY TIER

Tier

Simplete Richland 1 (HMO)

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

Also known as the “donut hole,” this stage begins when the amount you pay plus the amount we pay for your prescription drugs reaches $4,660. Here, you pay the following until you reach $7,400:

At this stage, you pay:

• 25% for covered generic drugs.

• 25% for covered brand-name drugs.

Initial Coverage

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

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.

Caring About You

Feeling like just a number in a system? That was the old way. Now there’s a new way. Simplete Medicare Advantage includes 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.

Health Coaching

Health coaches are your health partners. They’ll help you reach your health goals in the following areas and more:

• Nutrition.

• Weight loss.

• Staying active.

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 help 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

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.

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.

Turning Healthy Choices into Rewards

Paying for coverage you never use? That was the old way. Now there’s a new way. Simplete Medicare Advantage includes healthy living perks you can use every day. We want you to live a happy, healthy lifestyle, so we offer plenty of perks and incentive programs to help.

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.

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.

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.

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.

Perks, Programs and More

Preventive Care

At no additional cost to you, Simplete Medicare Advantage covers 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).

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 tobaccocessation 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.

Virtual Health Coverage

Get care when and where you need it with virtual health coverage. If you need to interact with your primary care provider (PCP) or specialist over the phone or online, you’re covered through the telehealth benefit. You don’t even need to leave the comfort of your home. Copayment may apply.

You can also get care for common conditions like allergies, cold, flu and pink eye from anywhere you have phone or internet connection in the U.S. Whether at home or traveling, you can talk to a board certified doctor or counselor by phone or secure video through hally.com at any time of the day, any day of the year.

Wellness Rewards

Take steps toward better health while working your way toward a $50 gift card. Have a yearly wellness visit or physical, plus complete two other activities outlined at simplete.org/perks to qualify for your $50 gift card.

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.

Coverage While You Travel

Peace of Mind on Vacation

You deserve a plan that keeps up with your travel plans. Here is how Simplete Medicare Advantage gives you peace of mind while on vacation.

Access to Worldwide Emergency and Urgent Care

If you’re having a medical emergency, you shouldn’t have to worry about your coverage. Simplete Medicare Advantage provides access to virtual health coverage in the United States and a Nurse Advice Line worldwide so you can get care and answers to health questions whether you’re at home or away.

Assist America®

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 non-medical services, as needed.

Here are just some of the services that are included:

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

• Emergency medical evacuation.

• Help returning home if you need medical care.

• Lost luggage assistance.

• Interpreter and legal referrals.

*Members may have additional costs related to travel services.

Coverage on the Go

Stressing about health coverage when you travel? That was the old way. Now there’s a new way. Simplete Medicare Advantage includes global coverage for emergency and urgent care, plus additional travel assistance through Assist America®.

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.

Travel Coverage FAQs

What if something happens and I get admitted to the hospital or have to have surgery while traveling?

• If it’s an urgent or emergency situation, we’ll still cover your claims at the in-network level anywhere you go.

• Once you’re stabilized, we ask that you return to in-network providers to ensure we can coordinate your recovery.

What happens if I need routine care (like diabetes blood checks) while staying out of network for an extended period of time?

• An HMO plan doesn’t cover this.

What if I need to see a specialist while out of network?

• You’ll need to receive prior authorization from Simplete Medicare Advantage for your claims to be covered.

• If the specialist is in the Simplete network, we don’t require a referral or prior authorization to go to that provider. The specialist may request that you get a referral from your primary care provider (PCP), but that’s the specialist’s policy, not a Simplete Medicare Advantage policy.

Summary of Benefits

This section gives you a summary of what this plan covers and what you pay. It doesn’t list every service we cover or every limitation or exclusion. For a complete list of covered services, call us and ask for the Evidence of Coverage (EOC).

This information is available in other formats, such as braille and large print. For more information, call (877) 561-8307 (TTY 711), daily from 8 a.m. to 8 p.m. local time. Voicemail is used on holidays and weekends from April 1 to September 30.

How to Enroll in Simplete Medicare Advantage

Timelines and Requirements

The Centers for Medicare & Medicaid Services (CMS) sets certain times during the year when people can enroll in a Medicare Advantage or prescription drug plan.

Annual Enrollment Period

From October 15 to December 7, you can enroll in Medicare Advantage or a stand-alone prescription drug plan, or you can switch plans. If you enroll during this period, your coverage begins January 1 of the following year.

Initial Enrollment Period

You have a seven-month initial enrollment period to enroll in Original Medicare, Medicare Advantage or a prescription drug plan. It starts three months before the month you turn 65, includes the month you turn 65 and ends three months after the month you turn 65.

• If you enroll one to three months before your 65th birthday, your coverage begins the first day of the month you turn 65.

• If you enroll during your birth month, your coverage begins the first day of the following month.

• If you enroll one to three months after the month you turn 65, your coverage begins the first day of the month after you enroll.

Open Enrollment Period

From January 1 to March 31, if you’re already on a Medicare Advantage plan, you can switch to Original Medicare (and join a stand-alone prescription drug plan).

Or you can switch from one Medicare Advantage plan to another.

Special Enrollment Period

You can enroll in a new plan or change your plan in certain situations. Here are some examples:

• Permanent address change.

• Loss of coverage due to employment change.

• Becoming eligible for a low-income subsidy.

Contact us for other situations that qualify.

Who’s eligible for our plans?

• You must have Medicare Parts A and B and live in the service area.

• You must continue to pay your Medicare Part B premium if not otherwise paid for by Social Security or another third party.

Enrollment in the plan will automatically disenroll you from any other Medicare Advantage plan. Enrollment in the plan won’t automatically disenroll you from a Medicare Supplement plan. You must contact that plan to disenroll.

Enrollment Process

Enrolling Online

Visit simplete.org/medicare to get started.

Enrolling by Phone

Call (877) 561-8307 (TTY 711), daily from 8 a.m. to 8 p.m. local time. Voicemail is used on holidays and weekends from April 1 to September 30.

Enrolling by Mail

Fill out and mail us the enrollment form in the back of this book. You can also download it from simplete.org/medicare.

Simplete Application Processing Center

3310 Fields South Dr. Champaign, IL 61822

Broker

If you attend a seminar, the person presenting can schedule an appointment to help you enroll.

After You Enroll

If you enroll in a Medicare Advantage plan during the Annual Enrollment Period, your coverage will begin January 1, 2023. In the meantime, we’ll help you get settled with the following:

• Member materials, which we’ll mail to you.

• Member ID card to use at the doctor, hospital and pharmacy, instead of your red, white and blue Medicare card.

Late Enrollment Penalty

If you don’t enroll in a prescription drug (Part D) plan when you’re first eligible, you may have to pay a penalty for enrolling later. That penalty will increase for every month you didn’t have prescription coverage.

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 give us a call and someone will help you with the filing process.

Grievance

File a 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.

See all your benefits in one place. See your complete coverage details anytime at simplete.org/medicare. Our secure member website stores important plan information in one easy place.

Carle Richland Star Ratings

Click on the link below to view the most up-to-date star ratings for your service area.

2022 Star Ratings

2023 Star Ratings (Available Mid-October 2022)