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

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%.

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

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Contact lenses

Vision	Not covered

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Eyeglass frames

Vision	Not covered

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Eyeglass lenses

Vision	Not covered

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Eyeglasses (frames and lenses)

Vision	Not covered

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Other

Vision	Not covered

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Routine eye exam

Vision	Not covered

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Upgrades

Vision	Not covered

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Transportation	Not covered
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
In-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

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Occupational therapy visit

In-Network Rehabilitation services	20% coinsurance
Out-of-Network Rehabilitation services	20% coinsurance

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Physical therapy and speech and language therapy visit

In-Network Rehabilitation services	20% coinsurance
Out-of-Network Rehabilitation services	20% coinsurance

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Cleaning

Preventive dental	Not covered

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Dental x-ray(s)

Preventive dental	Not covered

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Fluoride treatment

Preventive dental	Not covered

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Oral exam

Preventive dental	Not covered

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In-Network Preventive care	$0 copay
Out-of-Network Preventive care	20% coinsurance
In-Network Outpatient hospital coverage	20% coinsurance per visit
Out-of-Network Outpatient hospital coverage	20% coinsurance per visit
In-Network Other health plan deductibles?	No
Optional supplemental benefits	No

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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

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Outpatient group therapy visit

In-Network Mental health services	$0 copay
Out-of-Network Mental health services	20% coinsurance

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Outpatient group therapy visit with a psychiatrist

In-Network Mental health services	$0 copay
Out-of-Network Mental health services	20% coinsurance

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Outpatient individual therapy visit

Out-of-Network Mental health services	20% coinsurance
In-Network Mental health services	$0 copay

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Outpatient individual therapy visit with a psychiatrist

Out-of-Network Mental health services	20% coinsurance
In-Network Mental health services	$0 copay

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Chemotherapy

Out-of-Network Medicare Part B drugs	20% coinsurance
In-Network Medicare Part B drugs	20% coinsurance

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Other Part B drugs

In-Network Medicare Part B drugs	20% coinsurance
Out-of-Network Medicare Part B drugs	20% coinsurance

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Diabetes supplies

In-Network Medical equipment/supplies	20% coinsurance per item
Out-of-Network Medical equipment/supplies	20% coinsurance per item

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

Out-of-Network Medical equipment/supplies	20% coinsurance per item
In-Network Medical equipment/supplies	$0 copay

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

In-Network Medical equipment/supplies	$0 copay
Out-of-Network Medical equipment/supplies	20% coinsurance per item

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Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$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

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Fitting/evaluation

Hearing	Not covered

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Hearing aids - inner ear

Hearing	Not covered

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Hearing aids - outer ear

Hearing	Not covered

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Hearing aids - over the ear

Hearing	Not covered

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Hearing exam

In-Network Hearing	20% coinsurance
Out-of-Network Hearing	20% coinsurance

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Health plan deductible	$226 per year for some in-network and out-of-network services.
In-Network Ground ambulance	20% coinsurance
Out-of-Network Ground ambulance	20% coinsurance

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Foot exams and treatment

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

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Routine foot care

Foot care (podiatry services)	Not covered

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Emergency

Emergency care/Urgent care	20% coinsurance per visit (always covered)

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Urgent care

Emergency care/Urgent care	20% coinsurance per visit (always covered)

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Primary

In-Network Doctor visits	$0 copay
Out-of-Network Doctor visits	20% coinsurance per visit

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Specialist

In-Network Doctor visits	$0 copay
Out-of-Network Doctor visits	20% coinsurance per visit

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Diagnostic radiology services (e.g., MRI)

In-Network Diagnostic procedures/lab services/imaging	20% coinsurance
Out-of-Network Diagnostic procedures/lab services/imaging	20% coinsurance

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Diagnostic tests and procedures

Out-of-Network Diagnostic procedures/lab services/imaging	20% coinsurance
In-Network Diagnostic procedures/lab services/imaging	20% coinsurance

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Lab services

Out-of-Network Diagnostic procedures/lab services/imaging	20% coinsurance
In-Network Diagnostic procedures/lab services/imaging	$0 copay

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Outpatient x-rays

In-Network Diagnostic procedures/lab services/imaging	20% coinsurance
Out-of-Network Diagnostic procedures/lab services/imaging	20% coinsurance

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Diagnostic services

Comprehensive dental	Not covered

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Endodontics

Comprehensive dental	Not covered

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Extractions

Comprehensive dental	Not covered

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Non-routine services

Comprehensive dental	Not covered

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Periodontics

Comprehensive dental	Not covered

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Prosthodontics, other oral/maxillofacial surgery, other services

Comprehensive dental	Not covered

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Restorative services

Comprehensive dental	Not covered

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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:

Source: CMS.

Plans as of Oct 1, 2022.

Last updated on December 03, 2022

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.