Simply More (HMO)

Simply More (HMO) H5471-083 Plan Details
4 out of 5 stars

Simply More (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Simply Healthcare.
Plan ID: H5471-083.

$0.00
Monthly Premium

Simply More (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Simply Healthcare.
Plan ID: H5471-083.

Simply More (HMO) H5471-083 Plan Details
4 out of 5 stars

Simply More (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Simply Healthcare.
Plan ID: H5471-083.

$0.00
Monthly Premium

Florida Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $3450
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:
$0.00 copay
Specialty Doctor Visit
In-Network:
$10.00 copay
Inpatient Hospital Care
In-Network:
Days 1-8: $50.00 per day / Days 9-90: $0.00 per day
Additional Hospital Days: Unlimited additional days
Urgent Care
Urgent Care: $10.00 copay
Urgently Needed Services Copay Waived with Inpatient Admission
Emergency Room Visit
Emergency Care: $75.00 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: $250.00 copay

Health Care Services and Medical Supplies

Simply More (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: $0.00 copay
Routine Chiropractic Services: $0.00 copay 12 visits each year
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 - $50.00 copay
Therapeutic Radiological Services: $0.00 - $50.00 copay
Outpatient Diagnostic Procedures/Tests: $0.00 - $50.00 copay
Diagnostic Radiological Services: $0.00 - $50.00 copay
Home Health Care
In-Network:
$0.00 copay
Mental Health Inpatient Care
In-Network:
Days 1-8: $50.00 per day / Days 9-90: $0.00 per day
Mental Health Outpatient Care
In-Network:
Individual and Group Sessions: $15.00 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 $50 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
12 routine foot care visits each year.
Skilled Nursing Facility Care
In-Network:
SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $55.00 per day

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:
Preventive Dental Services: $0.00 copay
This plan covers: 2 Exams, 2 Prophylaxis cleanings, 2 Series of bitewing films, and 1 Panoramic film every year.

Medicare Covered Dental: $0.00 copay
Comprehensive Dental Services: $0.00 copay
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(s) and hearing aid fitting/evaluation(s) every year. $2,000.00 maximum plan benefit for 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