Simply Level (HMO C-SNP)
Simply Level (HMO C-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Simply Healthcare
Plan ID: H5471-073
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Simply Level (HMO C-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Simply Healthcare
Plan ID: H5471-073
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| 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: $0.00 copay |
| Inpatient Hospital Care | In-Network: Days 1-5: $50.00 per day / Days 6-90: $0.00 per day Additional Hospital Days: Unlimited additional days |
| Urgent Care | Urgent Care: $0.00 copay |
| 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: $150.00 copay Per Trip Air Ambulance: 20% coinsurance |
Health Care Services and Medical Supplies
Simply Level (HMO C-SNP) 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: $0.00 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: $0.00 copay - $100.00 copay Therapeutic Radiological Services: $0.00 copay - $60.00 copay Outpatient Diagnostic Procedures/Tests: $0.00 copay - $100.00 copay Diagnostic Radiological Services: $0.00 copay - $100.00 copay |
| Home Health Care | In-Network: $0.00 copay |
| Mental Health Inpatient Care | In-Network: Days 1-5: $50.00 per day / Days 6-90: $0.00 per day |
| Mental Health Outpatient Care | In-Network: Individual and Group Sessions: $0.00 copay |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital - Surgery: $100.00 copay Observation Services: $0.00 copay Ambulatory Surgical Center: $0.00 copay |
| Outpatient Substance Abuse Care | In-Network: Individual and Group Sessions: $50.00 copay |
| Over-the-counter (OTC) Items | This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $75 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 Unlimited routine foot care visits each year. |
| Skilled Nursing Facility Care | In-Network: SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $150.00 per day |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental: This plan covers: 2 Exams, 2 Prophylaxis cleanings, 2 Series of bitewing films, and 1 Panoramic film every year. Comprehensive Dental: This plan covers up to: 2 Amalgam or resin fillings, 6 simple or surgical extractions (in 1 or more visits), 2 crowns, 1 root canal, 2 implants every year, 2 fixed partial dentures (bridges) 1 per arch every 5 years, periodontal scaling and root planing per quadrant every 3 years, 1 set of complete or partial dentures every five years, and 1 denture adjustment/reline every year. Medically necessary surgical procedures including analgesia. |
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 $300.00 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: $0.00 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 $1,500.00 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 |
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