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Simpra Advantage Assist (PPO I-SNP)

Benefits Summary and Overview

This page is a benefits summary and overview of key plan information for Simpra Advantage Assist (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 Assist (PPO I-SNP) in 2025, please refer to our full plan details page.

Simpra Advantage Assist (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 Assist (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 Assist (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.

Overview IconKey Plan Facts

Below are a few key facts and commonly-asked questions about Simpra Advantage Assist (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 Assist (PPO I-SNP), the main costs are as follows:

Monthly Premium

The Monthly Premium for this plan is $86.00. 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 $150.00 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 $10000.00 (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 $10000.00 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:

Regular visits to your primary care doctor are covered and will have a copay of $0 (no copay) and coinsurance of 0% (no coinsurance).

Specialist Visits:

Visits to specialists are covered and will have a copay of $30.00 and coinsurance of 0% (no coinsurance). Specialist visits may require a referral from your primary care doctor or prior authorization.

Emergency Room:

Trips to the Emergency Room are covered, and will have a copay of $90.00 and coinsurance of 0% (no coinsurance). Coverage may vary for in-network and out-of-network hospitals.

Urgent Care:

Trips to Urgent Care arecovered and will have a copay of $30.00 and coinsurance of 0% (no coinsurance). Coverage may vary for in-network and out-of-network hospitals.

Sign up for Simpra Advantage Assist (PPO I-SNP)

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Drug Coverage IconDrug Coverage

The Simpra Advantage Assist (PPO I-SNP) plan has a $150 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance for your medications, depending on the drug tier and the pharmacy you use. For example, standard generic drugs have a $15 copay, while preferred brand drugs have a $95 copay. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs. If you qualify for the low-income subsidy, you will pay $30.20 per month for Part D, otherwise the Part D premium is $70.20 per month.

Additional Benefits IconAdditional Benefits

The Simpra Advantage Assist (PPO I-SNP) plan offers a range of benefits, including inpatient hospital stays with a copay of $175 for days 1-6 and no copay for days 7-90. Outpatient services have varying copays, while primary care and physical therapy have no copay. The plan provides coverage for emergency services with a $90 copay, and hearing services with a $10 copay for exams, and vision services with a $30 copay for eye exams. Additional benefits include dental services with a $750 annual maximum, and home infusion services with a $35 copay for Part B insulin drugs. Diagnostic and radiological services have a coinsurance of at least 20%, and home health services have no copay. The plan also covers ambulance services, with a $150 copay for ground transport and 20% coinsurance for air ambulance.

Inpatient Hospital See details

Inpatient Hospital benefits, including acute and psychiatric care, are covered by the Simpra Advantage Assist (PPO I-SNP) plan. For days 1-6, the copay is $175, and for days 7-90, there is no copay.

Outpatient Services See details

Outpatient Services includes coverage for Outpatient Hospital Services with a $30-$50 copay, Observation Services with a $100 copay, Ambulatory Surgical Center (ASC) Services with a $50 copay, Individual and Group Sessions for Outpatient Substance Abuse with a $30 copay, and Outpatient Blood Services with 20% coinsurance. Prior authorization is required for some services.

Partial Hospitalization See details

Partial Hospitalization is covered by the Simpra Advantage Assist (PPO I-SNP) plan, but requires prior authorization. The copay for this benefit is $30.

Ambulance and Transportation Services See details

Ambulance and Transportation Services are covered by the Simpra Advantage Assist (PPO I-SNP) plan. Ground ambulance services have a $150 copay, while air ambulance services have a 20% coinsurance. Transportation services to any health-related location are not covered.

Emergency Services See details

Emergency Services are covered by the Simpra Advantage Assist (PPO I-SNP) plan, with a $90 copay and no coinsurance. Urgently Needed Services are covered with a $30 copay and no coinsurance, while Worldwide Emergency Services are not covered.

Primary Care See details

The Simpra Advantage Assist (PPO I-SNP) plan covers primary care physician services and occupational therapy services with no copay and no coinsurance, while chiropractic services are covered with 20% coinsurance. Physician specialist services have a $30 copay, and mental health specialty services have a $30 copay. Podiatry services are covered with 20% coinsurance for routine foot care, while other health care professional services and psychiatric services have a $30 copay. Physical therapy and speech-language pathology services are covered with no copay and no coinsurance, and additional telehealth benefits are covered with a 20% coinsurance and a copay between $0 and $30.

Preventive Services See details

The Simpra Advantage Assist (PPO I-SNP) plan covers Medicare-covered preventive services, and other preventive services like glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. However, the plan does not cover annual physical exams, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, fitness benefits, enhanced disease management, telemonitoring services, remote access technologies, home and bathroom safety devices and modifications, or counseling services.

Hearing Services See details

Hearing Services include hearing exams with a $10 copay, prescription hearing aids (all types) with a maximum benefit of $2,000 every two years, and routine hearing exams with no copay; however, fitting/evaluation for hearing aids, prescription hearing aids - inner ear, prescription hearing aids - outer ear, and prescription hearing aids - over the ear are not covered. OTC hearing aids are not covered.

Vision Services See details

Vision Services include eye exams with a $30 copay, and other eye exam services, both covered once per year. Eyewear is covered up to a combined maximum of $230 every year for both in and out-of-network services. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.

Dental Services See details

Dental services include coverage for Medicare dental services with 20% coinsurance, and other dental services with a maximum benefit of $750 per year. Oral exams are covered for one visit every six months, dental x-rays are covered for one per year, and prophylaxis (cleaning) is covered for one per year. Fluoride treatments, and Orthodontics are not covered, while Restorative Services, Endodontics, Prosthodontics, removable, Maxillofacial Prosthetics, and Oral and Maxillofacial Surgery are covered. Adjunctive General Services, Periodontics, Implant Services, and Prosthodontics, fixed are not covered.

Home Infusion bundled Services See details

Home Infusion bundled Services are covered under the Simpra Advantage Assist (PPO I-SNP) plan. The plan covers Medicare Part B insulin drugs with a $35 copay and a coinsurance between 0% and 20%, and covers Medicare Part B chemotherapy/radiation drugs and other Medicare Part B drugs with a coinsurance between 0% and 20%.

Dialysis Services See details

Dialysis Services are covered under the Simpra Advantage Assist (PPO I-SNP) plan, with a coinsurance between 20% and 20%.

Medical Equipment See details

Medical Equipment benefits include 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. Prosthetics/Medical Supplies have a 20% coinsurance for Medicare-covered devices and supplies, and Diabetic Equipment also has a coinsurance.

Diagnostic and Radiological Services See details

Diagnostic and Radiological Services include coverage for all diagnostic procedures and tests with a coinsurance of at least 20%, while lab services are not covered. Diagnostic Radiological Services and Therapeutic Radiological Services have a copay of $50, and outpatient X-ray services have a copay of $5.

Home Health Services See details

Home Health Services are covered by the Simpra Advantage Assist (PPO I-SNP) plan with no copay and no coinsurance, but require authorization. Additional Hours of Care and Personal Care Services are not covered.

Cardiac Rehabilitation Services See details

Cardiac Rehabilitation Services are covered, but the specific sub-services of Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services are not covered. Prior authorization is required.

Skilled Nursing Facility (SNF) See details

Skilled Nursing Facility (SNF) services are covered, but additional days beyond Medicare-covered and non-Medicare-covered stays are not covered. Prior authorization is required, and the plan charges cost sharing on the day of discharge.

Other Services See details

The Simpra Advantage Assist (PPO I-SNP) plan covers Over-the-Counter (OTC) Items with a maximum benefit of $235 every three months, but Acupuncture, Meal Benefit, 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 are not covered.

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