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Simply Level (HMO C-SNP) - H5471-075-000
$0.00
Monthly Premium
Simply Level (HMO C-SNP) is a HMO C-SNP Medicare Advantage (Medicare Part C) plan offered by Simply Healthcare
Plan ID: H5471-075-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Florida Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about Florida Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Enrollment may be limited to certain times of the year. See why you may be able to enroll.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $3,450.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| 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 |
| 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 per year. |
| Ambulance transportation | Ground Ambulance: $200.00 copay Per Trip Air Ambulance: 20% coinsurance |
Health Care Services and Medical Supplies
Simply Level (HMO C-SNP) covers a range of additional benefits. Learn more about Simply Level (HMO C-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| 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 equipment (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: $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 items | This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $85 every month. Unused OTC amounts expire at the end of each 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 (SNF) care | In-Network: Days 1 - 20: $0.00 per day / Days 21 - 100: $150.00 per day |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In-Network: Preventive Dental Services: $0.00 copay This plan covers: 2 exams, 2 prophylaxis cleanings, 2 series of bitewing films every year, and 1 panoramic film every three years. 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 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, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | 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 for eyeglasses or contact lenses every year. |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | 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 $2,000 maximum plan benefit for prescribed hearing aids every year. |
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | In-Network: $0.00 copay for Medicare Covered Preventive Services |
When reviewing Florida Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Florida that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Florida Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.