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Tribute Select (HMO-POS I-SNP) By Tribute Health Plans



Tribute Select (HMO-POS I-SNP) H1587 003 0 is a 2023 Medicare Advantage Special Needs Plan plan by Tribute Health Plans. This plan from Tribute Health Plans 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 Tribute Health Plans and not Original Medicare. All Medicare SNPs also provide Medicare additional Part-D drug coverage. Tribute Select (HMO-POS I-SNP) H1587-003 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.







2023 Medicare Special Needs Plan Details

Plan Name:Tribute Select (HMO-POS I-SNP)
Plan ID:H1587 003 0
Special Needs Type:Institutional
Provider:Tribute Health Plans
Plan Year:2023
Plan Type:Local HMO
Monthly Premium C+D:$26.10
Part C Premium:$0
Part D (Drug) Premium:$26.10
Part D Supplemental Premium$0
Total Part D Premium:$26.10
Drug Deductible:$505.00
Tiers with No Deductible:0
Benchmark:below the regional benchmark
Type of Medicare Health Plan:Defined Standard Benefit
Drug Benefit Type:Basic
Gap Coverage:No
Similar Plan: H1587-001


The Tribute Select (HMO-POS I-SNP) H1587-003 is available to residents to Medicare eligible seniors in Arkansas. All Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. Tribute Select (HMO-POS I-SNP) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you need special care for a physician specialist, your primary care physician will make the arrangements and tell you where you can go in the network. You will need your PCPs okay, called a referral. Without getting a referral or services received from out-of-network providers are not typically covered by the plan.



How much does Tribute Select (HMO-POS I-SNP) cost?


Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Tribute Health Plans 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. Tribute Select (HMO-POS I-SNP) has a monthly drug premium of $26.10 and a $505.00 drug deductible. This Tribute Health Plans plan offers a $26.10 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 Tribute Health Plans 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 $26.10. 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.


Tribute Health Plans 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 Tribute Health Plans 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 Tribute Select (HMO-POS I-SNP) medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $6.50 for 75% low-income subsidy $13.00 for 50% and $19.60 for 25%.


Full Assistance Premium:$0
75% Assistance Premium:$6.50
50% Assistance Premium:$13.00
25% Assistance Premium:$19.60


H1587-003 Formulary and Drug Coverage

Tribute Select (HMO-POS 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.

Drug Tier Copay
Preferred
Pharmacy		 Copay
Nonpreferred
Pharmacy
Tier 1 NA 25%
The complete Tribute Select (HMO-POS I-SNP) H1587-003 Formulary
*Initial Coverage Phase and 30 day supply





2023 Summary of Benefits

The benefit information provided is a summary of what Tribute Select (HMO-POS I-SNP) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Tribute Health Plans 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.

Wellness programs (e.g., fitness, nursing hotline)Covered


Contact lenses


VisionNot covered


Eyeglass frames


VisionNot covered


Eyeglass lenses


VisionNot covered


Eyeglasses (frames and lenses)


VisionNot covered


Other


VisionNot covered


Routine eye exam


VisionNot covered


Upgrades


VisionNot covered



TransportationNot covered
Out-of-Network Skilled Nursing FacilityIn 2023 the amounts for each benefit period are:
$0 copay for days 1 through 20
$200 copay per day for days 21 through 100
In-Network Skilled Nursing FacilityIn 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


In-Network Rehabilitation services20% coinsurance
Out-of-Network Rehabilitation services20% coinsurance


Physical therapy and speech and language therapy visit


In-Network Rehabilitation services20% coinsurance
Out-of-Network Rehabilitation services20% coinsurance


Cleaning


Preventive dentalNot covered


Dental x-ray(s)


Preventive dentalNot covered


Fluoride treatment


Preventive dentalNot covered


Oral exam


Preventive dentalNot covered



In-Network Preventive care$0 copay
Out-of-Network Preventive care20% coinsurance
In-Network Outpatient hospital coverage20% coinsurance per visit
Out-of-Network Outpatient hospital coverage20% coinsurance per visit
In-Network Other health plan deductibles?No
Optional supplemental benefitsNo


Inpatient hospital - psychiatric


In-Network Mental health servicesIn 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 servicesIn 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$0 copay
Out-of-Network Mental health services20% coinsurance


Outpatient group therapy visit with a psychiatrist


In-Network Mental health services$0 copay
Out-of-Network Mental health services20% coinsurance


Outpatient individual therapy visit


Out-of-Network Mental health services20% coinsurance
In-Network Mental health services$0 copay


Outpatient individual therapy visit with a psychiatrist


Out-of-Network Mental health services20% coinsurance
In-Network Mental health services$0 copay


Chemotherapy


Out-of-Network Medicare Part B drugs20% coinsurance
In-Network Medicare Part B drugs20% coinsurance


Other Part B drugs


In-Network Medicare Part B drugs20% coinsurance
Out-of-Network Medicare Part B drugs20% coinsurance


Diabetes supplies


In-Network Medical equipment/supplies20% coinsurance per item
Out-of-Network Medical equipment/supplies20% coinsurance per item


Durable medical equipment (e.g., wheelchairs, oxygen)


Out-of-Network Medical equipment/supplies20% coinsurance per item
In-Network Medical equipment/supplies$0 copay


Prosthetics (e.g., braces, artificial limbs)


In-Network Medical equipment/supplies$0 copay
Out-of-Network Medical equipment/supplies20% coinsurance per item



Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$8,300 In-network
Out-of-Network Inpatient hospital coverageIn 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 coverageIn 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


HearingNot covered


Hearing aids - inner ear


HearingNot covered


Hearing aids - outer ear


HearingNot covered


Hearing aids - over the ear


HearingNot covered


Hearing exam


In-Network Hearing20% coinsurance
Out-of-Network Hearing20% coinsurance



Health plan deductible$226 per year for some in-network and out-of-network services.
In-Network Ground ambulance20% coinsurance
Out-of-Network Ground ambulance20% coinsurance


Foot exams and treatment


Out-of-Network Foot care (podiatry services)20% coinsurance
In-Network Foot care (podiatry services)$0 copay


Routine foot care


Foot care (podiatry services)Not covered


Emergency


Emergency care/Urgent care20% coinsurance per visit (always covered)


Urgent care


Emergency care/Urgent care20% coinsurance per visit (always covered)


Primary


In-Network Doctor visits$0 copay
Out-of-Network Doctor visits20% coinsurance per visit


Specialist


In-Network Doctor visits$0 copay
Out-of-Network Doctor visits20% coinsurance per visit


Diagnostic radiology services (e.g., MRI)


In-Network Diagnostic procedures/lab services/imaging20% coinsurance
Out-of-Network Diagnostic procedures/lab services/imaging20% coinsurance


Diagnostic tests and procedures


Out-of-Network Diagnostic procedures/lab services/imaging20% coinsurance
In-Network Diagnostic procedures/lab services/imaging20% coinsurance


Lab services


Out-of-Network Diagnostic procedures/lab services/imaging20% coinsurance
In-Network Diagnostic procedures/lab services/imaging$0 copay


Outpatient x-rays


In-Network Diagnostic procedures/lab services/imaging20% coinsurance
Out-of-Network Diagnostic procedures/lab services/imaging20% coinsurance


Diagnostic services


Comprehensive dentalNot covered


Endodontics


Comprehensive dentalNot covered


Extractions


Comprehensive dentalNot covered


Non-routine services


Comprehensive dentalNot covered


Periodontics


Comprehensive dentalNot covered


Prosthodontics, other oral/maxillofacial surgery, other services


Comprehensive dentalNot covered


Restorative services


Comprehensive dentalNot 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 Tribute Select (HMO-POS I-SNP) requires you to live in that plan’s service area. The service area is listed below:

State: Medicare Arkansas




Source: CMS.

Plans as of Oct 1, 2022.

Last updated on

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.

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