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Tribute Select (I-SNP) Plan Details for Pike County, AR

This page provides coverage and cost details for Tribute Health Plans’s H1587-003-0 Medicare SNP plan for 2025. Enrollment is subject to eligibility.

CMS 2025 Rating: ☆☆☆☆☆*

*This plan is new and has not yet been rated by CMS.

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system. The Tribute Health Plans logo is a registered trademark.[2] Its use by MedicareWire is strictly for editorial purposes. This is not a solicitation of insurance.

This private health insurance option offers all of the same basic benefits as Original Medicare, but out-of-pocket costs are different. It may include additional benefits that Medicare Part A and Part B do not cover.

Individuals must meet all Institutional SNP qualification requirements to join this I-SNP plan.

Tribute Select Basic Plan Details

Plan ID
H1587-003-0
Plan Type
HMO-POS I-SNP
Plan Year
2025
Premium
$20.90/mo
Plus your Medicare Part B premium.
Health Plan Deductible
$0.00
Out-of-Pocket Maximum
9,350.00 /yr (in-network)
Part B Reduction
$0.00/mo
Drug Plan Benefit
Basic
$590.00 deductible
Supplemental Benefits
None
Availability
Pike County, AR
Insured By
Tribute Health Plans
Summary of Benefits

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Health Plan Out-of-Pocket Costs

The following table is a summary of the most common out-of-pocket costs you will incur if you join this Tribute Health Plans plan:

Doctor's Office Visits

Primary
Not Covered
Specialist
Not Covered

Emergency, Urgent, and Inpatient Hospital Coverage

Emergency room care
20% Coinsurance
Urgent care
20% Coinsurance
Ground ambulance
20% Coinsurance
Inpatient hospital care
Coming Soon
Skilled Nursing Facility
Unknown

Foot Care

Foot Exams and Treatments (Medicare-covered)
Not Covered
Routine Foot Care
Not Covered

Chiropractic Care

Medicare-covered chiropractic
Not Covered
Routine chiropractic
Not Covered

Mental Health Services

Outpatient individual therapy
Not Covered
Outpatient group therapy
Not Covered
Inpatient psychiatric hospital care
Coming Soon

Rehabilitation Services

Physical therapy and speech and language therapy
20% Coinsurance
Prior Authorization Required
Occupational therapy
20% Coinsurance
Prior Authorization Required

Medical Equipment and Supplies

Diabetes supplies
20% Coinsurance
Durable medical equipment
Not Covered
Prosthetics
20% Coinsurance

Diagnostics, Lab Services, and Imaging

Diagnostic radiology services
20% Coinsurance
Lab services
0% Coinsurance
Outpatient x-rays
20% Coinsurance
Diagnostic tests and procedures
20% Coinsurance

Medicare Part B Drugs

Chemotherapy
20% Coinsurance
Other Part B drugs (Medicare-covered)
20% Coinsurance

Dental Services

Medicare Covered Preventive Dental
Not Covered
Oral exam
Not Covered
Dental x-rays
Not Covered
Cleaning
Not Covered
Periodontics
Not Covered
Endodontics
Not Covered
Restorative Services
Not Covered

Hearing Aids and Services

Fitting/evaluation
Not Covered
Hearing aids
Not Covered
Hearing exam
Not Covered

Vision Services

Medicare-covered eye exam
20% Coinsurance
Routine eye exam
Not Covered
Eyewear benefits
None
If you qualify for Medicare Advantage but don't know where to begin, we have licensed insurance agents[1] at 1-855-728-0510 (TTY 711) who can answer your questions (Mon-Fri 5am-6pm, Sat 6am-5pm PT) and help you get enrolled. There's no obligation.

Prescription Drug Costs & Benefits

Tribute Select includes an basic benefit Medicare Part D plan (PDP). This simply means that the plan covers the minimum amount required by the Centers for Medicare & Medicaid Services, whereas enhanced benefit plans cover more.

Prescription Drug Premium with Extra Help

Extra Help is a Social Security program that helps people with limited income and resources lower or cut Part D costs. The following table outlines premium assistance details with Extra Help.

Low Income Premium Subsidy: ${part_d_lips_amount}
Low Income Premium Subsidy CMS Pays: $20.90
Low Income Subsidy Premium: $0.00

If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.

Prescription Drug Deductible

The Medicare Part D annual deductible with this plan is $590.00. You must pay this amount at the pharmacy before Tribute Health Plans begins paying its share.

Prescription Drug Out-of-Pocket Costs

In addition to the plan's monthly premium and deductible, Tribute Select has out-of-pocket costs you must pay when you pick up your prescriptions.

Drug Tier Retail Mail Order
Cost data not available.
*The Part D deductible does not apply.

How to Qualify to Enroll in
Tribute Select

To be eligible to enroll in Tribute Select, you must meet three requirements:

  1. You are eligible for Medicare;
  2. You live in Pike County (the plan’s service area); and
  3. You require the level of care provided in an institutionalized setting, such as a long-term care nursing facility, for 90 days or more.

If you live at home and require an equivalent level of skilled care, you may be eligible for an Institutional Equivalent Special Needs Plan (IE-SNP).

Before joining Tribute Select, consider these questions:

  • Does the plan's provider network include my nursing home or home care provider?
  • What costs should I expect with my coverage (premiums, deductibles, copayments)?
  • Is there an annual limit on my out-of-pocket costs?
  • Will I be able to use my doctors? Are they in the plan's network?
  • Are the plan's in-network providers and facilities in convenient locations?
  • Does the plan provide coverage for services I receive from out-of-network providers?
  • Do I need a referral to see a specialist?
  • Are my medications on the Part D plan's formulary?
  • What special accommodations does the plan make for persons with disabilities?
  • What special language and cultural accommodations does the plan make?