Simply Extra (HMO)
Simply Extra (HMO) H5471-105 Plan Details
Simply Extra (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Simply Healthcare
Plan ID: H5471-105
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
$0.00
Monthly Premium
Simply Extra (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Simply Healthcare
Plan ID: H5471-105
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Florida Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $100 |
| Out of Pocket Max |
In-Network: $3450 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | In-Network: $0.00 copay |
| Specialty Doctor Visit | In-Network: $40.00 copay |
| Inpatient Hospital Care | In-Network: Days 1-8: $225.00 per day / Days 9-90: $0.00 per day Additional Hospital Days: Unlimited additional days |
| Urgent Care | Urgent Care: $40.00 copay Urgently Needed Services Copay Waived with Inpatient Admission |
| Emergency Room Visit | Emergency Care: $135.00 copay Copay waived if admitted to hospital within 24 hours Worldwide Coverage: This plan covers urgent care and emergency services when traveling outside of the United States for less than six months. This benefit is limited to $100,000.00 per year. |
| Ambulance Transportation | Ground Ambulance: $250.00 copay Per Trip Air Ambulance: 20% coinsurance |
Health Care Services and Medical Supplies
Simply Extra (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Medicare Covered Chiropractic Services: $20.00 copay |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies: $0.00 copay |
| Durable Medical Eqipment (DME) | In-Network: 0% - 20% coinsurance depending on the equipment |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Lab Services: $0.00 copay X-Rays: $25.00 copay - $200.00 copay Therapeutic Radiological Services: $40.00 copay - 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 copay - $200.00 copay Diagnostic Radiological Services: $150.00 copay - $200.00 copay |
| Home Health Care | In-Network: $0.00 copay |
| Mental Health Inpatient Care | In-Network: Days 1-8: $225.00 per day / Days 9-90: $0.00 per day |
| Mental Health Outpatient Care | In-Network: Individual and Group Sessions: $40.00 copay |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital - Surgery: $200.00 copay Observation Services: $200.00 copay Ambulatory Surgical Center: $125.00 copay |
| Outpatient Substance Abuse Care | In-Network: Individual and Group Sessions: $40.00 copay |
| Over-the-counter (OTC) Items | This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $45 every month. Unused OTC amounts do not roll over from month to month. |
| Podiatry Services | In-Network: Medicare Covered Podiatry Services: $0.00 copay Routine Foot Care: $0.00 copay 3 routine foot care visit(s) each year. |
| Skilled Nursing Facility Care | In-Network: SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $75.00 per day |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive and Comprehensive Dental Combined Allowance This plan covers up to a $1,000 allowance for covered preventive and comprehensive dental services every year. Medicare Covered Dental: $0.00 copay Preventive Dental Services: $0.00 copay Comprehensive Dental Services: $0.00 copay |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Medicare Covered Eye Exam: $0.00 copay Routine Eye Exam: $0.00 copay This plan covers 1 routine eye exam(s) every year. Medicare Covered Eye Wear: $0.00 copay Routine Eye Wear: $0.00 copay This plan covers up to $225.00 for eyeglasses or contact lenses every year. |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Medicare Covered Hearing Exam: $40.00 copay Routine Hearing Exam: $0.00 copay for routine hearing exam(s). $0.00 copay for hearing aids up to the maximum plan benefit amount. This plan covers 1 routine hearing exam every year. This plan covers 1 routine hearing aid fitting evaluation and a $1,000.00 maximum plan benefit for prescribed hearing aids every year. |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services |
Prescription Drug Costs and Coverage
The Simply Extra (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $100 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $100 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $100 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $100 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
Find Medicare Advantage Plans
Visit MedicareAdvantage.com to compare multiple Medicare Advantage plans, side by side.
