A non-government entity
Simpra Advantage Dual Care (PPO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Simpra Advantage Dual Care (PPO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Simpra Advantage Dual Care (PPO D-SNP) in 2025, please refer to our full plan details page.
Simpra Advantage Dual Care (PPO D-SNP) is a PPO D-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 Dual Care (PPO D-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 Dual Care (PPO D-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 Dual Care (PPO D-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 Dual Care (PPO D-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:
Sign up for Simpra Advantage Dual Care (PPO D-SNP)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Simpra Advantage Dual Care (PPO D-SNP) plan has a $590 deductible for prescription drugs. After the deductible is met, you will pay the costs for your drugs based on the tier and pharmacy you use. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you will pay nothing for your Medicare Part D covered drugs. If you qualify for the low-income subsidy (LIS), your Part D premium will be $40.
Additional Benefits
The Simpra Advantage Dual Care (PPO D-SNP) plan offers a wide range of benefits with varying cost-sharing. Many services, including primary care, ambulance services, and home health services, have no copay. However, services like outpatient, partial hospitalization, and emergency services have a 20% coinsurance. The plan also includes coverage for hearing and vision services, with hearing exams and vision exams subject to coinsurance. Dental services are covered with a $3,000 annual maximum. Additionally, the plan offers coverage for home infusion, dialysis, medical equipment, and diagnostic services, all with coinsurance.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, with coinsurance costs as defined by Medicare and requiring prior authorization. Additional days for Inpatient Hospital-Acute, Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services includes coverage for all outpatient hospital services, observation services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services and observation services have a 20% coinsurance, and outpatient blood services has a 20% coinsurance. Outpatient substance abuse services have a 20% coinsurance for both individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization is covered by the Simpra Advantage Dual Care (PPO D-SNP) plan, but requires prior authorization. You will pay a 20% coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Simpra Advantage Dual Care (PPO D-SNP) plan, with no copay for ambulance services, but a 20% coinsurance applies for both ground and air ambulance services. Transportation services to a plan-approved health-related location are covered for up to 48 one-way trips per year via bus or subway, while transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered with a 20% coinsurance and no copay. Worldwide Emergency Services are not covered.
Primary Care See details
The Simpra Advantage Dual Care (PPO D-SNP) plan covers primary care physician services with no copay, and covers chiropractic services with 20% coinsurance. Occupational Therapy, Physician Specialist, Mental Health, Psychiatric, and Physical Therapy services are covered with 20% coinsurance, and additional telehealth benefits have a coinsurance between 0% and 20%.
Preventive Services See details
The Simpra Advantage Dual Care (PPO D-SNP) plan covers preventive services including an annual physical exam with no copay. The plan also covers kidney disease education services and other preventive services such as glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit, all with a 20% coinsurance. However, health education, in-home safety assessments, personal emergency response systems, and several other additional preventive services are not covered.
Hearing Services See details
Hearing services are partially covered by the Simpra Advantage Dual Care (PPO D-SNP) plan, with hearing exams subject to at most 20% coinsurance. Prescription hearing aids are covered up to a maximum of $2,500 every two years for in-network services only, while routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids - inner ear, prescription hearing aids - outer ear, prescription hearing aids - over the ear, and OTC hearing aids are not covered.
Vision Services See details
The Simpra Advantage Dual Care (PPO D-SNP) plan covers vision services, including eye exams with a 20% coinsurance. The plan also covers eyewear with a combined maximum of $400 per year, contact lenses (12 pairs per year), and eyeglasses (lenses and frames) (1 pair per year). However, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Simpra Advantage Dual Care (PPO D-SNP) plan covers Medicare Dental Services with 20% coinsurance, other dental services with a $3,000 annual maximum, oral exams (2 per year), dental x-rays (1 per year), and prophylaxis (cleaning, 2 per year). Fluoride treatment, Adjunctive General Services, Periodontics, Implant Services, and Orthodontics are not covered, and Restorative Services, Endodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, and Oral and Maxillofacial Surgery all require prior authorization.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Simpra Advantage Dual Care (PPO D-SNP) plan. You will pay a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits are covered under the Simpra Advantage Dual Care (PPO D-SNP) plan, including Durable Medical Equipment, Prosthetics/Medical Supplies, and Diabetic Equipment. For Durable Medical Equipment, there is a 20% coinsurance with no copay, and prior authorization is required, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance with no copay. For Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts, there is a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Simpra Advantage Dual Care (PPO D-SNP) plan. 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 under the Simpra Advantage Dual Care (PPO D-SNP) plan with no copay and no coinsurance, but 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 covered, but the plan does not cover the sub-services. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered, but prior authorization is required. The plan does not cover additional days beyond Medicare-covered for SNF or non-Medicare-covered stays for SNF.
Other Services See details
The Simpra Advantage Dual Care (PPO D-SNP) 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. The plan does cover Over-the-Counter (OTC) Items with a maximum benefit coverage amount of $210.00 every month, but does not cover all drugs on the CMS OTC list.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved