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WELCOME BOOKLET
Welcome to Simplete. Simplete® is a new approach to healthcare designed to deliver more benefits, more perks and fewer hassles. Every day, we’re working to make Simplete 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 member.
Have questions? Contact Simplete Member Services: (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
Walk-In Hours: Weekdays 8:30 a.m. to 4:30 p.m. *Walk-in hours may change during this time of COVID-19. Please call ahead to confirm.
Local 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.
What Makes Simplete Unique Streamlined Relationships
Prevention Simplete helps prevent health issues before they start with free preventive care, including free screenings, flu shots and more.
Through streamlined relationships with leading providers, Simplete lowers costs, reduces the red tape and makes your coverage comprehensive.
Community Focus We've focused on you and your community by working side by side with doctors who know your needs.
Care Coordinators
Wellness Perks
We make navigating your Medicare plan easier with free care coordination and health coaching, as well as 24/7 virtual care services.
Simplete makes living a healthier life easier with gym and fitness class reimbursements, wellness goal setting and rewards.
Ease of Use Instead of managing multiple plans, you can access all your healthcare needs under one plan, including vision, dental, hearing, pharmacy and more.
How to Access Care Member Services
Telehealth Benefit
We’re here to help. Call us at (877) 933-8481 (TTY 711) 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.
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.
Primary Care Provider (PCP) Find your Simplete PCP online using our Find Care tool at simplete.org/find-care. You can also call our care coordination team for assistance at (877) 933-8481 (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. With the telehealth benefit, you can 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. And with the virtual visit benefit, you can connect with a board certified doctor or counselor by phone, secure video or our member app, 24/7.
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 the Hally® app, 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’re experiencing an injury or illness anywhere in the world, Simplete 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® App Manage your health plan and get the care you need anytime, anywhere. •
See all your account activities in one place.
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Access your virtual ID card.
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Search for doctors and other resources.
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Quickly connect with a doctor over virtual visits.
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Get cost estimates.
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Check claims status.
Visit the App Store or Google Play to download. App Store is a service mark of Apple Inc., registered in the U.S. and other countries. Google Play and the Google Play logo are trademarks of Google LLC.
Coverage While You Travel When you travel 100 miles or more from home, Simplete 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.
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Medical referrals.
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Emergency medical evacuation.
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Lost luggage assistance.
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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
Dental 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.
Simplete members get $1,500 each year for services Original Medicare doesn’t cover. Your dentist can submit a claim for you directly to us (Simplete) using the claims information on the back of your member ID card.
Acupuncture
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:
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.
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Oral exams.
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Cleanings.
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X-rays.
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You don’t need prior authorization.
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You can choose any acupuncture provider.
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Fluoride treatments.
A per-visit copay may apply (varies by plan).
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Fillings.
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Dentures.
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Denture adjustments and repairs.
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Crowns.
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Treatments for gum disease.
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Bridge work.
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Root canals and extractions.
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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.
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 information about specific Simplete plan benefits and cost information.
Hearing Benefit Through TruHearing®, you can get one routine hearing exam for a $45 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.
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Local, professional care from an accredited doctor in your area.
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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.
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Natural, lifelike sound in virtually all listening situations.
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A worry-free purchase with a 60-day trial and three-year warranty.
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Clearer speech, even in noisy environments.
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80 free batteries per aid included with non-rechargeable models.
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Ability to stream audio and phone calls directly to your ears from your smartphone*.
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Guides to help you adapt to your new hearing aids at TruHEARING.com/GetStarted.
Personalized Care Receive expert care from a team of helpful professionals. •
Guidance and assistance from a TruHearing consultant.
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
TRUHEARING AID COST BREAKDOWN Your Plan
Simplete Riverside 1 Simplete Riverside 2 Simplete Riverside 3
TRUHEARING ADVANCED 19 32 CHANNELS | 6 PROGRAMS
TRUHEARING PREMIUM 19** 48 CHANNELS | 6 PROGRAMS
Retail: $2,445/aid
Retail: $3,125/aid
$699 copay/aid
$999 copay/aid
ROUTINE EXAM IN NETWORK***
$45 exam copay
* Smartphone-compatible hearing aids connect directly to iPhone®, iPad® and iPod® Touch devices. Connectivity also available on many Android® phones with use of a phone clip accessory. **Rechargeable battery upgrade option on TruHearing Premium 19 RIC Li for $50 per aid. ***Must be performed by a TruHearing network provider.
Drug Coverage With Simplete, 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.
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.
Understanding Drug Tiers
Drug Reimbursement
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:
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.
Tier 1 - Preferred Generic
Tier 2 - Generic Tier 3 - Preferred Brand Tier 4 - Non-Preferred Drug Tier 5 - Specialty Tier
Pharmacy Partnerships Simplete 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/find-care
Save with Simplete.
Easy Pharmacy Benefits
Simplete offers special savings programs to help you lower the cost of your medications further. Here are some of the ways you can save with Simplete:
Enjoy convenient pharmacy benefits, including:
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).
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The Social Security Administration at (800) 772-1213, 7 a.m. to 7 p.m., Monday through Friday (TTY 800-325-0778).
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The state’s Medicaid office.
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 doctor or 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.
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/find-care. There, you can also search for your prescription and estimate your costs for the year.
COSTS IN THE INITIAL COVERAGE PERIOD 30-DAY DRUG COST BY TIER
Simplete Riverside 1 Simplete Riverside 2 Simplete Riverside 3
Tier 1 - $2 Tier 2 - $15 Tier 3 - $47 Tier 4 - 50% Tier 5 - 33%
Catastrophic Coverage This coverage begins when your out-of-pocket drug costs r each $7,050. At this stage, we pay for most of your drug costs f or the rest of the year, while you pay the greater of the following:
$7,050
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5% of the cost.
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$3.95 for covered generic drugs. (including brand-name drugs treated as generic)
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$9.85 for covered brand-name drugs.
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Coverage Gap $4,430
This begins when the amount you pay plus the amount we pay for your prescription drugs reaches $4,430. At this stage, you pay:
Drug Cost Breakdown
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25% for covered generic drugs.
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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.
Find in-network pharmacies or check the formulary at simplete.org/find-care.
Call Member Services at (877) 933-8481 (TTY 711) if you have questions.
Coverage Through the Gap If your total prescription spend adds up to $4,430, 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 $7,050.
Simplete is powered by Health AllianceTM – 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 includes wellness perks and a care coordination team to help you live a healthy lifestyle.
Care Coordination and Health Coaching Team What Truly Sets Simplete Apart
Core Team
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.
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Understanding and managing health issues, like diabetes and asthma.
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Coordinating care for complicated health conditions.
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Optimizing health benefits to save money.
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Helping prevent illness and hospital stays.
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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.
Care Manager
Member
Primary Care Provider
Extended Team
Dietitian
Social Worker
Care Management Representative
Medical Director
Pharmacist
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.
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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.
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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.
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At any time, our team can help you with making healthy lifestyle changes, including eating better, working out and more.
Perks, Programs and More With Simplete, 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 covers many preventive services, including:
Be Fit With our Be Fit program, you get a free membership to Riverside Health Fitness Center or a reimbursement of up to $360 a year for a variety of fitness activities, like the following and more: •
Fitness class fees.
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Bowling.
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Gym memberships.
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Tennis.
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Online fitness subscriptions.
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Pickleball.
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Recreational league fees.
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Pool exercise classes.
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5K/10K race fees.
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Annual wellness visits.
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Routine cancer screenings (including mammograms and colonoscopies).
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Cardiovascular disease risk-reduction visits.
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Ski memberships.
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Rowing.
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Flu shots.
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Golf.
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Bone mass measurements.
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Depression, diabetes and HIV screenings.
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Hepatitis B and pneumococcal shots.
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Medical nutrition therapy.
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Obesity screening and therapy.
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Screening and counseling to reduce alcohol misuse.
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Screening for sexually transmitted infections (STIs) and counseling to prevent STIs.
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Counseling to stop smoking or tobacco use.
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“Welcome to Medicare” preventive visit (one time).
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Weight loss subscriptions.
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, personal trainers or personal equipment.
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.
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.
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.
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A personalized quit plan.
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Helpful tools, like Text2Quit®.
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Web Coach®, an online learning and support community.
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.
Additional Resources — 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:
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 (877) 933-8481 (TTY 711) 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.
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If you set up Social Security withdrawal.
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If you set up recurring payments using our mail-in form or online at simplete.org/pay.
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Log in at simplete.org or hally.com to review your doctor and pharmacy directory.
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If your policy was terminated and the account has a $0 balance.
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Download our helpful Hally app to find in-network providers.
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 Simplete pays 80%, and you pay 20%.
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 agent of record (AOR) can start the authorization over the phone.
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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, in the member app and are also mailed to you. •
Review your Evidence of Coverage (EOC).
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Review your Annual Notice of Change (ANOC). The ANOC for your plan is mailed every September.
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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.
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Download our helpful Hally app to find in-network providers.
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. •
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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 autodraw form to us and have the payment taken from your credit card or bank account via automated clearing house.
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Pay your premium via Social Security withdrawal.
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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 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. 10. How do I register online at simplete.org, and why should I sign up? To create an account, go to simplete.org. There, you can: •
Go paperless by accessing your materials online.
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Print member ID cards.
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Compare costs with the Treatment Cost Calculator.
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View past and current claims, authorizations and your Summary of Benefits (SOB).
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Check your deductible and out-of-pocket spending.
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Look up doctors, hospitals and pharmacies covered by your plan.
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Pay your premiums.
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Use one of your free virtual visits.
Common Healthcare Terms Appointed Representative (AOR): 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 form CMS-1696, available from Simplete 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. 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 immunizations. 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 primary care provider (PCP), you can go to an urgent (or convenient) care clinic.
You can find other common healthcare terms in your 2022 benefits guide.
Member Terms Rights and Responsibilities As a Simplete 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 Simplete 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
Disenrollment
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.
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.
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.
Call Member Services for more information on voluntary and involuntary disenrollment.
Plan Protections If you ever have an issue with your plan, Simplete makes it easy to reach out. If you have any grievances or want to appeal a decision, just call Member Services at (877) 933-8481 (TTY 711) 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.
Simplete Member Services (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
MDMBSI22-RIVhandbk-0621 • H1463_22_98544_C