2019 Simplete 1 (HMO) H1463-23-0 in IL from Health Alliance Medicare | HealthPocket

Benefits & Coverage

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderHealth Alliance Medicare
Plan IDH1463-23-0
Plan Year2019
CMS Rating
Plan TypeHMO
Annual Deductible$0.00
Out-of-Pocket Maximum4000

What To Know About This Plan
  • This plan has health and drug coverage
  • This plan is available for 2020. see plan

Why We Like This Plan
  • has both Health and Drug Coverage
  • has no additional premium costs outside of your Medicare Part B premium
  • has a copay of $0 for Tier 1 preferred generic drugs (30 day supply, preferred retail pharmacies)
  • was the 3rd best selling plan in Cook in 2020

Costs and Other Important Information

Plan Year2019
Monthly Health Plan Premium$0.00
Monthly Drug Plan Premium$0.00
Health Plan Deductible$0
Other health plan deductibles?No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$4,000 In-network
Optional Supplemental BenefitsNo

Benefits

SERVICECOST
Inpatient hospital coverage$200 per day for days 1 through 8
$0 per day for days 9 through 60
$100 per day for days 61 through 90
Outpatient hospital coverage$100 per visit
Doctor visitsPrimary:$5 per visit
Specialist:$10 per visit
Preventive care$0 copay
Emergency care/Urgent careEmergency:$90 per visit (always covered)
Urgent care:$40 per visit (always covered)
Diagnostic procedures/lab services/imagingDiagnostic tests and procedures:$10
Lab services:$10
Diagnostic radiology services (e.g., MRI):$50
Outpatient x-rays:$10
Mental health servicesInpatient hospital - psychiatric:$200 per day for days 1 through 6
$0 per day for days 7 through 60
$100 per day for days 61 through 90
Outpatient group therapy visit with a psychiatrist:$40
Outpatient individual therapy visit with a psychiatrist:$40
Outpatient group therapy visit:$40
Outpatient individual therapy visit:$40
Skilled Nursing Facility$0 per day for days 1 through 20
$170 per day for days 21 through 100
Rehabilitation servicesOccupational therapy visit:$40
Physical therapy and speech and language therapy visit:$40
Ground ambulance$220
TransportationNot covered
Foot care (podiatry services)Foot exams and treatment:$50
Routine foot care:Not covered
Medical equipment/suppliesDurable medical equipment (e.g., wheelchairs, oxygen):0-20% per item
Prosthetics (e.g., braces, artificial limbs):20% per item
Diabetes supplies:0-20% per item
Wellness programs (e.g., fitness, nursing hotline)Covered
Medicare Part B drugsChemotherapy:20%
Other Part B drugs:20%

Benefits Services

Hearing
Hearing exam$25
Fitting/evaluationNot covered
Hearing aids$699-999There may be limits on how much the plan will provide.
Preventive Dental
Oral exam$20There may be limits on how much the plan will provide.
Cleaning$0 copay. There may be limits on how much the plan will provide.
Fluoride treatmentNot covered
Dental x-ray(s)Not covered
Comprehensive Dental
Non-routine services$0 copay
Diagnostic services$0 copay
Restorative services$0 copay
Endodontics$0 copay
Periodontics$0 copay
Extractions$0 copay
Prosthodontics, other oral/maxillofacial surgery, other services$0 copay
Vision
Routine eye exam$0 copay. There may be limits on how much the plan will provide.
OtherNot covered
Contact lensesNot covered
Eyeglasses (frames and lenses)Not covered
Eyeglass framesNot covered
Eyeglass lensesNot covered
UpgradesNot covered

Coverage Area for Simplete 1 (HMO)

StateIllinois
CountyCook

All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit


30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$0 copay$5 copayNot offered
Tier 2: Non-Preferred Generic$15 copay$15 copayNot offered
Tier 3: Preferred Brand Name$47 copay$47 copayNot offered
Tier 4: Non-Preferred Brand Name50% coinsurance50% coinsuranceNot offered
Tier 5: Specialty Tier33% coinsurance33% coinsuranceNot offered

60 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$0 copay$10 copayNot offered
Tier 2: Non-Preferred Generic$30 copay$30 copayNot offered
Tier 3: Preferred Brand Name$94 copay$94 copayNot offered
Tier 4: Non-Preferred Brand Name50% coinsurance50% coinsuranceNot offered
Tier 5: Specialty Tier33% coinsurance33% coinsuranceNot offered
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$0 copay$12.5 copayNot offered
Tier 2: Non-Preferred Generic$30 copay$37.5 copayNot offered
Tier 3: Preferred Brand Name$94 copay$117.5 copayNot offered
Tier 4: Non-Preferred Brand Name50% coinsurance50% coinsuranceNot offered
Tier 5: Specialty Tier33% coinsurance33% coinsuranceNot offered

Staying healthy - screenings, tests and vaccines

Breast cancer screening
Colorectal cancer screening
Annual flu vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring physical ability
Adult BMI assessment

Managing Chronic Conditions

Special needs plan care managementNot Rated
Care for older adults – medication reviewNot Rated
Care for older adults – functional status assessmentNot Rated
Care for older adults – Pain screeningNot Rated
Osteoporosis management in women who had a fracture
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Controlling blood pressure
Rheumatoid arthritis management
Reducing the risk of falling
Plan all-cause readmissions

Member Experience with Health Plan

Getting needed care
Getting appointments and care quickly
Customer service
Overall rating of health care quality
Overall rating of plan
Care Coordination

Member Complaints, and Changes in Health Plan's Performance

Complaints about the health plan
Members choosing to leave the health plan
Beneficiary access and performance problems
Health plan quality improvement

Health Plan Customer Service

Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability - Medical

Drug Plan Customer Service

Call center – foreign language interpreter and TTY/TDD availability - Drugs
Appeals auto-forward
Appeals upheld

Member Complaints, and Changes in Drug Plan's Performance

Complaints about the drug plan
Members choosing to leave the drug plan
Beneficiary access and performance problems
Drug plan quality improvement

Member Experience with Drug Plan

Rating of drug plan
Getting needed prescription drugs

Drug Pricing and Patient Safety

MPF Price Accuracy
High risk medication
Part D medication adherence for diabetes
Part D medication adherence for hypertension
Part D medication adherence for cholesterol
Medication Therapy Management program completion rate
Statin Use in Persons with Diabetes

Physicians that accept Simplete 1 (HMO) for Illinois

get free advice

Speak With A Licensed Agent

Call (800) 931-6467

Learn More

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Health Insurance Innovations, Inc. family of companies (NASDAQ: HIIQ).

Medicare Plans Found

 

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Health Insurance Innovations, Inc. family of companies (NASDAQ: HIIQ).