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Simpra Advantage Nursing Home Plan (PPO I-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Simpra Advantage Nursing Home Plan (PPO I-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Simpra Advantage Nursing Home Plan (PPO I-SNP) in 2025, please refer to our full plan details page.
Simpra Advantage Nursing Home Plan (PPO I-SNP) is a PPO I-SNP plan offered by Associated Care Ventures, Inc. available for enrollment in 2025 to people living in Alabama statewide. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Simpra Advantage Nursing Home Plan (PPO I-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Simpra Advantage Nursing Home Plan (PPO I-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Simpra Advantage Nursing Home Plan (PPO I-SNP).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Simpra Advantage Nursing Home Plan (PPO I-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $40.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $590.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $14000.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $14000.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Simpra Advantage Nursing Home Plan (PPO I-SNP) has a $590 deductible for prescription drugs. After the deductible, you will pay costs for drugs in each tier until your total drug costs reach $2000. The plan's formulary has not specified the costs for the different tiers. If you qualify for the low-income subsidy (LIS), your monthly premium for Part D will be $40. Once your yearly out-of-pocket drug costs reach $2000, you will enter the catastrophic coverage phase, where you pay nothing for Medicare Part D covered drugs.
Additional Benefits
The Simpra Advantage Nursing Home Plan (PPO I-SNP) provides coverage for a range of services, including inpatient and outpatient care with coinsurance costs, and covers emergency services with a 20% coinsurance. You'll also find coverage for primary care, preventive services, hearing, vision, and dental services, with varying coinsurance amounts. Additional benefits include home infusion services, dialysis, and medical equipment, all with coinsurance costs. The plan also offers transportation, and home health services with no copay. However, it's important to note that certain services like cardiac rehabilitation, additional days in the hospital or SNF, and several other services are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric services, are covered, but additional days, non-Medicare-covered stays, and upgrades for both are not covered. You will pay the Medicare-defined cost share for tier 1, and prior authorization is required.
Outpatient Services See details
Outpatient services are covered, including all outpatient hospital services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient Hospital Services and Observation Services have a 20% coinsurance. Ambulatory Surgical Center Services and Outpatient Substance Abuse Services have a minimum coinsurance of 20% and a maximum coinsurance of 20%. Outpatient Blood Services have a 20% coinsurance.
Partial Hospitalization See details
Partial Hospitalization is covered under the Simpra Advantage Nursing Home Plan (PPO I-SNP) and requires prior authorization. You will pay 20% coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services includes coverage for ground and air ambulance services, each with a 20% coinsurance, and transportation services to plan-approved health-related locations, with 8 one-way trips per year via bus/subway. Transportation services to any health-related location is not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services, are covered under this plan with a 20% coinsurance, and no copay. Worldwide Emergency Services are not covered.
Primary Care See details
The Simpra Advantage Nursing Home Plan (PPO I-SNP) covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, podiatry services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services, occupational therapy services, and physical therapy and speech-language pathology services have a 20% coinsurance. Primary care physician services, physician specialist services, individual and group sessions for mental health specialty services, routine foot care, individual and group sessions for psychiatric services, and physical therapy and speech-language pathology services have a 20% coinsurance. Additional telehealth benefits have a 0% - 20% coinsurance. Routine chiropractic care is not covered. Routine foot care is covered for 6 visits every year.
Preventive Services See details
The Simpra Advantage Nursing Home Plan (PPO I-SNP) covers preventive services including Medicare-covered services with no copay. Other services like Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit have a 20% coinsurance. However, services such as annual physical exams, health education, and others are not covered.
Hearing Services See details
Hearing Services include hearing exams and prescription hearing aids. Hearing exams have a coinsurance of at most 20% and are covered once per year, while prescription hearing aids (all types) are covered up to $2,000 every two years. Prescription Hearing Aids - Inner Ear, Outer Ear, and Over the Ear are not covered, nor are OTC hearing aids.
Vision Services See details
Vision services include eye exams with a 20% coinsurance, and eyewear with a combined maximum benefit of $230 per year for both in-network and out-of-network services. Contact lenses and eyeglasses (lenses and frames) are covered, while eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services are partially covered under the Simpra Advantage Nursing Home Plan (PPO I-SNP) with 20% coinsurance, but orthodontic services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics, maxillofacial prosthetics, implant services, prosthodontics, and oral and maxillofacial surgery are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, Medicare Part B Chemotherapy/Radiation Drugs with 0-20% coinsurance, and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for this benefit.
Dialysis Services See details
Dialysis Services are covered by the Simpra Advantage Nursing Home Plan (PPO I-SNP), with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment is covered by the Simpra Advantage Nursing Home Plan (PPO I-SNP), including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance. Diabetic Supplies and Therapeutic Shoes/Inserts each have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Simpra Advantage Nursing Home Plan (PPO I-SNP). Diagnostic Procedures/Tests and Diagnostic Radiological Services have a coinsurance of at most 20%, while Lab Services have no coinsurance.
Home Health Services See details
Home Health Services are covered by the Simpra Advantage Nursing Home Plan (PPO I-SNP) with no copay and no coinsurance; however, additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Simpra Advantage Nursing Home Plan (PPO I-SNP). The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, or Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered, but the plan does not cover additional days beyond Medicare-covered days or non-Medicare-covered stays. Prior authorization is required. The plan charges the Medicare-defined cost share for tier 1 and offers zero days.
Other Services See details
Other Services include Over-the-Counter (OTC) Items, with a maximum benefit of $300 every three months that carries over if unused, but the plan does not cover Acupuncture, Meal Benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services.
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