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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.
2023 BIG-PICTUREPoweredGUIDEbyHealthAlliance™
Get more out of Medicare with Medicare Advantage. Comfort of having an in-network primary care provider to oversee all your Replacescare.Original Medicare. May cover benefits that Original Medicare doesn’t. No medical underwriting. Lower premiums than Medicare Supplement plans. Who pays in what order: health plan, you. Not age- or tobacco-rated. Generally gives you the flexibility to see any doctor who accepts Original SupplementsMedicare.Original Medicare. Only covers expenses covered by Original Medicare. Medical underwriting. (except for guaranteed issue plans) Higher premiums than Medicare Advantage plans. Who pays in what order: Original Medicare, health plan, you. Age- and tobacco-rated. Medicare Advantage Medicare Supplement
Advantage
Medicare vs. Medicare Supplement
Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium.
• Tier 1 (Preferred Generic).
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%).
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.
• Tier 2 (Generic).
Inpatient hospital care: The amount you pay for a stay in an in-network hospital.*
Primary care provider (PCP) visit: The amount you pay at the doctor’s office when you visit your in-network primary care doctor.*
• Tier 4 (Non-Preferred Drug).
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.
• Tier 5 (Specialty Tier).
Drug tier: The cost group a drug belongs to. Drugs in our Medicare Part D formulary are in one of five groups:
Outpatient surgery: What you pay for an outpatient procedure.
Skilled nursing facility (SNF): What you pay for an approved stay at a SNF.
Helpful Terms
Urgent care: The amount you pay for urgent or convenient care.
* 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.
• Tier 3 (Preferred Brand).
Specialist visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.*
Medical deductible: What you pay out-of-pocket before your coverage starts. Our plans don’t have medical deductibles.
Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare.
Emergency care: The amount you pay for emergency care, like a trip to the emergency department.
Lab: What you pay for lab services, like blood tests.
Ambulance: What you pay for an ambulance ride in an emergency.
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.
2021 BIG PICTURE GUIDE Key: This is a summary of commonly used benefits. † Members on POS plans may pay more for preventive care out of network. » Non-emergency cost-sharing may vary. Contact the plan for details. *** Emergency care available worldwide. The out-of-network yearly limit includes your combined costs for both in-network and out-of-network care. + Also called convenient or walk-in care. ^ You pay nothing for days 91 and beyond in network. & Dollar amounts listed for inpatient hospital care and SNF are amounts you pay per day. 1 2 3 4 5 Plan Costs Office Visits DiagnosticServices Emergency Services Hospital Services Initial Rx Coverage (for 30-day supply; applies only to Rx plans) Plan Type Network Premium MedicalDeductible Yearly Limit (does not include pharmacy) PCP Visit Specialist Visit VisitVirtual TherapyPhysical Chiropractic Lab X-Ray CT/MRI Ambulance Care***Emergency CareUrgent+ HospitalOutpatientCare Inpatient Hospital Care^& (including services received) Skilled Nursing Facility& (noncustodial care based on medical necessity) Rx Deductible Rx Cost by Tier Rx Gap Coverage 1 2 3 4 5 1 Simplete Richland 1 (HMO) Tier 1 $0 $0 $4,000 $0 $25 $0 $40 $15 $10 $10 $50 $220 $110 $40 $100 $200/Day (1-8), $0 (Days 9+) $0/Day (1-20), $196 (Days 21-100) $0 $2 $15 $47 50% 33% Tier 1 Coverage Through the Gap 2 POS Basic (HMO-POS) In-Network $23 $0 $6,700 $35 $50 $0 $40 $20 $40 $40 $40 $350 $95 $60 25% $450/Day (1-4), $0 (Days 5+) $0/Day (1-20), $196 (Days 21-100) N/A N/A N/A N/A N/A N/A N/A Out-of-Network $0 $11,300 $50 $65 $0 $50 $50 $50 $50 $50 $350 $95 $60 25% $600/Day (1-6), $0 (Days 7-90) $100/Day (1-20), $200 (Days 21-100) N/A N/A N/A N/A N/A N/A N/A 3 POS Basic Rx (HMO-POS) In-Network $53 $0 $6,700 $15 $50 $0 $40 $20 $40 $50 $50 $350 $95 $60 25% $450/Day (1-4), $0 (Days 5+) $0/Day (1-20), $196 (Days 21-100) $0 $2 $15 $47 50% 33% Tier 1 Coverage Through the Gap Out-of-Network $0 $11,300 $50 $65 $0 $50 $50 $50 $50 $50 $350 $95 $60 25% $600/Day (1-6), $0 (Days 7-90) $100/Day (1-20), $200 (Days 21-100) $0 $2 $15 $47 50% 33% Tier 1 Coverage Through the Gap Perks and Programs Air Ambulance Get access to air ambulance services (when medically necessary) at a $220 copay. $350 for POS Basic and POS Basic Rx plans. Be Fit Get fit with a $360/year reimbursement on a variety of fitness activities. Care Coordination Connect to a team of providers who work with your doctor to make sure you have the resources you need. Dental Coverage Get help paying for dental services, like cleanings, X-rays and more, with coverage up to $2,000 a year. Hearing Benefit Get one routine hearing exam for a $0 copay when you see a TruHearing® provider and lowered rates on up to two TruHearing hearing aids per year. OTC4Me Get 10% off on over-the-counter (OTC) products online or by phone. Contact us. (877) 561-8307 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1 – September 30 simplete.org/medicare Virtual Health Coverage Telehealth Benefit Connect with your primary care provider or specialist over the phone or online without the inconvenience of going to the doctor’s office or sitting in a waiting room. Copayment may apply. Virtual Visits Talk to a board certified doctor or counselor by phone or secure video through hally.com, 24/7. Vision Coverage Get access to vision services beyond what Original Medicare covers, including a $150 allowance for eyewear. Wellness Rewards Earn a $50 gift card for taking specific healthy steps.
Health Alliance™ Medicare complies with applicable Federal civil rights laws and does not discriminate on the basis 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). 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. MDMKSI23-CRMILNfoldguide-0622 • H1463_23_108828_M