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Simply Level (C-SNP) H5471 080 0 Plan Details

This page provides coverage and cost details for Simply Healthcare Plans, Inc.’s H5471-080-0 Medicare SNP plan for 2025. Enrollment is subject to eligibility.

CMS 2025 Rating: ☆☆☆☆☆*

*CMS rated this Simply Healthcare Plans, Inc. plan (H5471-080-0) 4.5 (Good+) out of 5 stars.

Best Insurance Company Ranking
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system. The Simply Healthcare Plans, Inc. 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 Chronic or Disabling Condition SNP qualification requirements to join this C-SNP plan.

Simply Level Basic Plan Details

Plan ID
H5471-080-0
Plan Type
HMO C-SNP
Plan Year
2025
Premium
$0.00/mo
Plus your Medicare Part B premium.
Health Plan Deductible
$0.00
Out-of-Pocket Maximum
3,450.00 /yr (in-network)
Part B Reduction
$0.00/mo
Drug Plan Benefit
Enhanced
$0.00 deductible
Supplemental Benefits
Vision, Hearing
Availability
See List
Insured By
Simply Healthcare Plans, Inc.

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 Simply Healthcare Plans, Inc. plan:

Doctor's Office Visits

Primary
$0 Copay
Specialist
$0 Copay
Referral Required

Emergency, Urgent, and Inpatient Hospital Coverage

Emergency room care
$135 Copay
Urgent care
$0 Copay
Ground ambulance
$200 Copay
Inpatient hospital care
$0.00 per stay
Skilled Nursing Facility
$0.00 per day for days 1 through 20
$40.00 per day for days 21 and beyond

Foot Care

Foot Exams and Treatments (Medicare-covered)
$0 Copay
Routine Foot Care
$0 Copay

Chiropractic Care

Medicare-covered chiropractic
$0 Copay
Prior Authorization Required, Referral Required
Routine chiropractic
$0 Copay
Prior Authorization Required, Referral Required

Mental Health Services

Outpatient individual therapy
$15 Copay
Outpatient group therapy
$15 Copay
Inpatient psychiatric hospital care
$0.00 per stay

Rehabilitation Services

Physical therapy and speech and language therapy
$15 Copay
Prior Authorization Required, Referral Required
Occupational therapy
$15 Copay
Prior Authorization Required, Referral Required

Medical Equipment and Supplies

Diabetes supplies
$0 Copay
Prior Authorization Required
Durable medical equipment
20% Coinsurance
Prior Authorization Required
Prosthetics
20% Coinsurance

Diagnostics, Lab Services, and Imaging

Diagnostic radiology services
$100 Copay
Prior Authorization Required, Referral Required
Lab services
$0 Copay
Prior Authorization Required, Referral Required
Outpatient x-rays
$100 Copay
Prior Authorization Required, Referral Required
Diagnostic tests and procedures
$100 Copay
Prior Authorization Required, Referral Required

Medicare Part B Drugs

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

Dental Services

Medicare Covered Preventive Dental
$0 Copay
Prior Authorization Required
Oral exam
$0 Copay
Dental x-rays
$0 Copay
Cleaning
$0 Copay
Periodontics
Not Covered
Endodontics
Not Covered
Restorative Services
Not Covered

Hearing Aids and Services

Fitting/evaluation
Covered
Limits may apply
Hearing aids
Not Covered
Hearing exam
Covered
Limits may apply

Vision Services

Medicare-covered eye exam
$0 Copay
Routine eye exam
$0 Copay
1 Every year
Eyewear benefits
None

Prescription Drug Costs & Benefits

Simply Level includes enhanced benefit Medicare Part D. Enhanced benefits offer greater coverage than basic, typically providing lower cost-sharing, broader drug coverage, and additional benefits, such as covering drugs not included in the standard formulary. These plans usually have higher premiums due to the extra coverage and flexibility they provide, but they cover a larger percentage of overall drug costs.

As of 2023, approximately 75% of people on Medicare are enrolled in enhanced plans.

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: $0.00
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 $0.00. You must pay this amount at the pharmacy before Simply Healthcare Plans, Inc. begins paying its share.

Prescription Drug Out-of-Pocket Costs

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

Drug Tier Retail Mail Order
Preferred Generic$0.00$0.00
Generic$0.00$0.00
Preferred Brand$15.00$15.00
Non-Preferred Drug$75.00$75.00
Specialty Tier33.00%33.00%
Supplemental Drugs$0.00$0.00
*The Part D deductible does not apply.

How to Qualify to Enroll in
Simply Level

To be eligible to enroll in Simply Level, you must meet these requirements:

  1. You are eligible for Medicare;
  2. You live in Broward County (the plan’s service area); and
  3. You have been diagnosed with one or more severe or disabling chronic conditions.

A disabling 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