2024 Simply Level C-SNP: H5471-070-0 for Polk County, FL
What is Plan H5471-070-0 by Simply Healthcare Plans?
Simply Level is a C-SNP Medicare Advantage plan, by Simply Healthcare Plans, for 2024. It has a HMO provider network. Delivery of healthcare services and costs are significantly different than in Original Medicare, and the plan offers additional benefits that are not included with Medicare Part A and Part B.
You must meet all qualification requirements to join this C-SNP plan.
This plan is rated 5.0 (Excellent) stars by CMS making it a top-rated plan.
Plan Basics | |
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Plan ID: | H5471-070-0 |
Plan Type: | HMO |
Plan Year: | 2024 |
Premium: | $0.00/mo Plus your Part B premium. |
Health Plan Deductible: | $0.00 |
Out-of-Pocket Maximum: | /yr |
Part B Reduction: | $65.00/mo |
Drug Plan Benefit: | Enhanced $0.00 deductible |
Rx Gap Coverage: | {gap} |
Supplemental Benefits: | Vision, Hearing |
Availability: | Polk County, FL |
Insured By: | Simply Healthcare Plans |
Summary of Benefits |
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Health Plan Costs & Benefits
Simply Level is a Health Maintenance Organization (HMO) plan. HMO plan members usually receive health care services through the plan’s local network of providers. Referrals are almost always required to see a specialist and other providers. However, Simply Level does allow out-of-network care for emergencies and out-of-area dialysis.
The following table is a summary of the most common out-of-pocket costs you will incur if you join this Simply Healthcare Plans plan:
Healthcare Service | Member Cost |
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Doctor Visits (In-Network) | |
Primary: | $0 Copay |
Specialist: | $0 Copay Referral Required |
Wellness programs (e.g., fitness, nursing hotline): | |
Preventive care: | $0 Copay |
Foot Care (In-Network) | |
Foot exams and treatment (Medicare-covered): | $0 Copay |
Routine foot care: | $0 Copay |
Chiropractic Care (In-Network) | |
Medicare-covered chiropractic care: | $0 Copay Authorization Required, Referral Required |
Routine chiropractic care: | $0 Copay Authorization Required, Referral Required |
Emergency Care / Urgent Care | |
Emergency room care: | $135 Copay |
Urgent care: | $0 Copay |
Ground ambulance: | $100 Copay |
Inpatient hospital coverage: | $0.00 per stay |
Outpatient hospital coverage: | $0 Copay Authorization Required, Referral Required |
Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $40.00 per day for days 21 and beyond |
Optional supplemental benefits: | Not Covered |
Mental Health Services (In-Network) | |
Outpatient individual therapy visit with a psychiatrist: | $15 Copay |
Outpatient group therapy visit with a psychiatrist: | $15 Copay |
Inpatient hospital - psychiatric: | $0.00 per stay |
Outpatient group therapy visit: | $15 Copay |
Outpatient individual therapy visit: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy visit: | $15 Copay Authorization Required, Referral Required |
Occupational therapy visit: | $15 Copay Authorization Required, Referral Required |
Medical Equipment / Supplies (In-Network) | |
Diabetes supplies: | $0 Copay Authorization Required |
Durable medical equipment (e.g., wheelchairs, oxygen): | 20% Coinsurance Authorization Required |
Prosthetics (e.g., braces, artificial limbs): | 20% Coinsurance |
Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
Diagnostic radiology services (e.g., MRI): | $50 Copay Authorization Required, Referral Required |
Lab services: | $0 Copay Authorization Required, Referral Required |
Outpatient x-rays: | $25 Copay Authorization Required, Referral Required |
Diagnostic tests and procedures: | $25 Copay Authorization Required, Referral Required |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 20% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our Simply Level Summary of Benefits information.
Supplemental Health Plan Benefits (H5471-070-0)
The following is a summary of the supplemental benefits Simply Healthcare Plans includes with this plan:
Supplemental Healthcare Service | Member Cost |
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Preventive Dental | |
Oral exam (In-Network) | Not Covered |
Fluoride treatment (In-Network) | Not Covered |
Dental x-ray(s) (In-Network) | Not Covered |
Cleaning (In-Network) | Not Covered |
Comprehensive Dental | |
Periodontics (In-Network) | Not Covered |
Non-routine services (In-Network) | Not Covered |
Diagnostic services (In-Network) | Not Covered |
Extractions (In-Network) | Not Covered |
Endodontics (In-Network) | Not Covered |
Restorative services (In-Network) | Not Covered |
Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
Hearing | |
Fitting/evaluation (In-Network) | $0 Copay Authorization Required |
Hearing aids (In-Network) | Covered Limits may apply |
Hearing exam (In-Network) | $0 Copay Authorization Required |
Vision | Maximum vision benefit: | $400.00 Every year |
Eyeglasses (frames and lenses) (In-Network) | $0 Copay |
Routine eye exam (In-Network) | $0 Copay |
Contact lenses (In-Network) | $0 Copay |
Additional Supplemental Benefits
None specified.
Prescription Drug Plan Costs & Benefits
Simply Level includes an enhanced benefit Medicare Part D plan (PDP). Enhanced plans have a higher actuarial value than basic plans. Actuarial value simply refers to the percentage of cost that's covered by the plan.
Prescription Drug Plan Premium
Although the prescription drug plan (Part D) premium is bundled with the total plan cost, some plans have supplemental costs and/or offer low-income subsidy (LIS) assistance. The following table outlines the prescription drug plan premium details of this plan.
Basic Part D Premium: | -$17.00 |
Supplemental Part D Premium: | $17.00 |
Total Part D Premium: | $0.00 |
Part D Premium with Full LIS Assistance: | $0.00 |
For more information about the Low-Income Subsidy (aka, "Extra Help") program, refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $0.00. This is the amount you must pay at the pharmacy before Simply Healthcare Plans begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Simply Level has out-of-pocket costs that you must pay when you pick up your prescriptions. The following table shows you those costs.
Drug Tier | Preferred | Standard |
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1 (Preferred Generic) | N/A | $0.00 copay |
2 (Generic) | N/A | $0.00 copay |
3 (Preferred Brand) | N/A | $0.00 copay |
4 (Non-Preferred Brand) | N/A | $40.00 copay |
5 (Specialty Tier) | N/A | 33% |
CMS 5-Star Rating Marks
Each year CMS rates Medicare Special Needs Plans in nine broad categories based on a 5-star system. The table below shows the quality ratings for this Simply Healthcare Plans plan.
CMS Measure | Star Rating |
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2024 Overall Rating | |
Staying Healthy: Screenings, Tests, Vaccines | |
Managing Chronic (Long Term) Conditions | |
Member Experience with Health Plan | |
Complaints and Changes in Plans Performance | |
Health Plan Customer Service | |
Drug Plan Customer Service | |
Complaints and Changes in the Drug Plan | |
Member Experience with the Drug Plan | |
Drug Safety and Accuracy of Drug Pricing |
How to Qualify to Enroll in
Simply Level
To be eligible to enroll in Simply Level, you must meet these requirements:
- You are eligible for Medicare;
- You live in Polk County (the plan’s service area); and
- You have been diagnosed with one or more severe or disabling chronic conditions.
A disabiling chronic condition (disease) is one that lasts one or more years and requires ongoing medical attention and/or limits activities of daily living. They include:
- Autoimmune disorders
- End-stage renal disease
- Cancer
- Cardiovascular disorders
- Hematologic disorders
- HIV/AIDS
- Chronic heart failure
- Chronic lung disorders
- Neurologic disorders
- Dementia
- Diabetes
- End-stage liver disease
- Neurologic disorders
- Stroke
- Mental health conditions
This plan is for individuals with cardiovascular disorders, chronic heart failure, and/or diabetes.
Additional C-SNP Plan Options
Here are some additional Medicare SNP plans that might be worth reviewing:
Contact Simply Healthcare Plans
Plan Website: | http://shop.simplyhealthcareplans.com/medicare |
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Formulay Information: | http://www.simplyhealthcareplans.com/medicare/prescription-drug-benefits |
Pharmacy Information: | Simply Healthcare Plans Pharmacy Page |
Prospective Members: | (855)679-0554 |
TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Advantage program on www.medicare.gov.
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, GlobalHealth, Health Care Service Corporation, Cigna Healthcare, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Scott and White Health Plan now part of Baylor Scott & White Health, UnitedHealthcare(R), and Wellcare.
Citations & References
- Simply Healthcare Plans, http://shop.simplyhealthcareplans.com/medicare, Last Accessed October 13, 2023
- Medicaid.gov, "Medicaid & CHIP in Florida", Last Accessed January 4, 2024
- CMS.gov, "Chronic Condition Special Needs Plans (C-SNPs)", Last Accessed January 20, 2023
- CMS.gov, Landscape Source Files, Last Accessed January 2, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed January 2, 2024
- CMS.gov, Plan Benefits Package, Last Accessed January 3, 2024