Simpra Advantage (PPO I-SNP) H4091 001 0 is a 2023 Medicare Advantage Special Needs Plan plan by Simpra Advantage. This plan from Simpra Advantage works with Medicare to give you significant coverage beyond original Medicare. If you decide to sign up you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Simpra Advantage and not Original Medicare. All Medicare SNPs also provide Medicare additional Part-D drug coverage.
Simpra Advantage (PPO I-SNP) H4091-001 is an Institutional SNP (I-SNP). An Institutional SNP is for beneficiaries who live in an institution such as a nursing
home or require nursing care at home. If you live in an institution like a nursing home or hospital you can join any Medicare SNP you qualify for or switch plans at any time.
The Simpra Advantage (PPO I-SNP) H4091-001 is available to residents to
Medicare eligible seniors in Alabama.
All Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage.
Simpra Advantage (PPO I-SNP) is a Local PPO. A preferred provider organization (PPO) is a medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.
How much does Simpra Advantage (PPO I-SNP) cost?
Part-C Premium
A monthly premium is the fee you pay to the plan in exchange for coverage. Simpra Advantage charges a $0 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.
Part-D Deductible and Premium
An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. Simpra Advantage (PPO I-SNP) has a monthly drug premium of $35.20 and a $505.00 drug deductible. This Simpra Advantage plan offers a $35.20 Part-D Basic Premium that is below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0. This Premium covers any enhanced plan benefits offered by Simpra Advantage above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $35.20. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.
Simpra Advantage Gap Coverage
In 2023 once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Simpra Advantage plan does not offer additional coverage through the gap.
Extra Help Premium Assistance
The Low Income Subsidy (LIS) Extra Helps people with Medicare pay for prescription drugs and lowers the costs of Medicare prescription drug coverage. Income limits are based on the Federal Poverty Level (FPL), which changes every year in February or March. The 2022 income limit is $1,719 ($2,309 for couples) per month. Depending on your income level you may be eligible for a full 75%, 50%, 25% premium assistance. The Simpra Advantage (PPO I-SNP) medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $8.80 for 75% low-income subsidy $17.60 for 50% and $26.40 for 25%.
Full Assistance Premium:
$0
75% Assistance Premium:
$8.80
50% Assistance Premium:
$17.60
25% Assistance Premium:
$26.40
H4091-001 Formulary and Drug Coverage
Simpra Advantage (PPO I-SNP) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers.
By reviewing different Medicare Drug formularies, you can pick a Medicare Special Needs Plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.
The benefit information provided is a summary of what Simpra Advantage (PPO I-SNP) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Simpra Advantage helps
get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.
In 2023 the amounts for each benefit period are: $0 copay for days 1 through 20 $200 copay per day for days 21 through 100
Out-of-Network Skilled Nursing Facility
In 2023 the amounts for each benefit period are: $0 copay for days 1 through 20 $200 copay per day for days 21 through 100
Occupational therapy visit
Out-of-Network Rehabilitation services
20% coinsurance
In-Network Rehabilitation services
20% coinsurance
Physical therapy and speech and language therapy visit
In-Network Rehabilitation services
20% coinsurance
Out-of-Network Rehabilitation services
20% coinsurance
Cleaning
Preventive dental
Not covered
Dental x-ray(s)
Preventive dental
Not covered
Fluoride treatment
Preventive dental
Not covered
Oral exam
Preventive dental
Not covered
Out-of-Network Preventive care
$0 copay
In-Network Preventive care
$0 copay
Out-of-Network Outpatient hospital coverage
20% coinsurance per visit
In-Network Outpatient hospital coverage
20% coinsurance per visit
In-Network Other health plan deductibles?
No
Optional supplemental benefits
No
Inpatient hospital - psychiatric
In-Network Mental health services
In 2023 the amounts for each benefit period are: $1,600 deductible for days 1 through 60 $400 copay per day for days 61 through 90
Out-of-Network Mental health services
In 2023 the amounts for each benefit period are: $1,600 deductible for days 1 through 60 $400 copay per day for days 61 through 90
Outpatient group therapy visit
In-Network Mental health services
20% coinsurance
Out-of-Network Mental health services
20% coinsurance
Outpatient group therapy visit with a psychiatrist
In-Network Mental health services
20% coinsurance
Out-of-Network Mental health services
20% coinsurance
Outpatient individual therapy visit
Out-of-Network Mental health services
20% coinsurance
In-Network Mental health services
20% coinsurance
Outpatient individual therapy visit with a psychiatrist
In-Network Mental health services
20% coinsurance
Out-of-Network Mental health services
20% coinsurance
Chemotherapy
In-Network Medicare Part B drugs
20% coinsurance
Out-of-Network Medicare Part B drugs
20% coinsurance
Other Part B drugs
Out-of-Network Medicare Part B drugs
20% coinsurance
In-Network Medicare Part B drugs
20% coinsurance
Diabetes supplies
Out-of-Network Medical equipment/supplies
20% coinsurance per item
In-Network Medical equipment/supplies
20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)
Out-of-Network Medical equipment/supplies
20% coinsurance per item
In-Network Medical equipment/supplies
20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)
Out-of-Network Medical equipment/supplies
20% coinsurance per item
In-Network Medical equipment/supplies
20% coinsurance per item
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$12,450 In and Out-of-network $8,300 In-network
Out-of-Network Inpatient hospital coverage
In 2023 the amounts for each benefit period are: $1,600 deductible for days 1 through 60 $400 copay per day for days 61 through 90
In-Network Inpatient hospital coverage
In 2023 the amounts for each benefit period are: $1,600 deductible for days 1 through 60 $400 copay per day for days 61 through 90
Fitting/evaluation
Out-of-Network Hearing
$0 copay
In-Network Hearing
$0 copay
Hearing aids
Out-of-Network Hearing
$0 copay
In-Network Hearing
$0 copay
Hearing exam
Out-of-Network Hearing
20% coinsurance
In-Network Hearing
20% coinsurance
Health plan deductible
$1,600 per year for inpatient hospital services and $226 for outpatient services with a total plan deductible of $1,826 per year from in-network and out-of-network providers.
Prosthodontics, other oral/maxillofacial surgery, other services
Comprehensive dental
Not covered
Restorative services
Comprehensive dental
Not covered
In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
No
Coverage Area
(Click county or state to compare all available Advantage plans)
The availability of Medicare Special Need Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Simpra Advantage (PPO I-SNP) requires you to live in that plan’s service area. The service area is listed below:
Notes: Data are subject to change. All contracts for 2023 have not been finalized. For 2023, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part Part D benefit.
Includes 2023 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.
Site Search:
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Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.
Every year, Medicare evaluates plans based on a 5-star rating system.
