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Simply Level (HMO C-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Simply Level (HMO C-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Simply Level (HMO C-SNP) in 2026, please refer to our full plan details page.
Simply Level (HMO C-SNP) is a HMO C-SNP plan offered by Elevance Health, Inc. available for enrollment in 2025 to people living in Polk. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Simply Level (HMO C-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Simply Level (HMO C-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 Simply Level (HMO C-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 Simply Level (HMO C-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $65.00. You must continue to pay paying your reduced 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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3450.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
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 Simply Level (HMO C-SNP) Medicare plan features a $0 drug deductible, allowing your prescription coverage to begin immediately. You will pay no copay for Tier 1 preferred generic, Tier 2 generic, and Tier 6 supplemental drugs when filled at preferred pharmacies, standard pharmacies, or through standard mail order. For Tier 3 preferred brand drugs, the plan features a $10 copay for a one-month supply, $20 for a two-month supply, and $30 for a three-month supply. Tier 4 non-preferred drugs require a $55 copay for a one-month supply at preferred pharmacies and standard mail order, or a $60 copay at standard pharmacies. Specialty medications in Tier 5 require a 33% coinsurance for a one-month supply across preferred, standard, and standard mail-order pharmacies.
Additional Benefits
The Simply Level (HMO C-SNP) plan offers comprehensive coverage designed to minimize out-of-pocket costs for essential medical services. Members enjoy no copay and no coinsurance for inpatient hospital stays, primary care and specialist doctor visits, home health care, and laboratory services. Emergency room visits carry a $140 copay, which is waived if you are admitted, while urgently needed care requires no copay. This plan also features valuable supplemental benefits to support your everyday well-being, including dental, vision, and hearing coverage with no copays. You can access up to $1,500 in dental benefits, a $400 eyewear allowance, and up to $3,000 for prescription hearing aids annually. Additionally, the plan covers up to 24 one-way transportation trips per year and diabetic equipment at no cost, though some items like dialysis and durable medical equipment require a coinsurance of up to 20 percent.
Inpatient Hospital See details
Inpatient hospital services are partially covered by Simply Level (HMO C-SNP) with no copay and no coinsurance for Medicare-covered acute and psychiatric stays. Prior authorization and referrals are required, and while three additional acute care days are covered at no cost, psychiatric additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Simply Level (HMO C-SNP) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Outpatient hospital services have a copay of $0 to $100 (including a $100 copay per stay for observation services), while outpatient substance abuse sessions require a $50 copay.
Partial Hospitalization See details
Partial hospitalization is covered by Simply Level (HMO C-SNP) with no copay and no coinsurance, though prior authorization and a referral are required.
Ambulance and Transportation Services See details
Simply Level (HMO C-SNP) covers ground ambulance services with a $200 copay and air ambulance services with a 20% coinsurance, both requiring prior authorization. Transportation services are partially covered with no copay and no coinsurance for up to 24 one-way trips per year to plan-approved locations, while trips to any health-related location are not covered.
Emergency Services See details
Emergency services are covered by Simply Level (HMO C-SNP) with a $140 copay (waived if admitted to the hospital within 24 hours) and no coinsurance, while urgently needed services are covered with no copay and no coinsurance. Worldwide emergency, urgent, and transportation services are also covered up to a $100,000 maximum benefit with a $140 copay and no coinsurance per service.
Primary Care See details
Primary care benefits under Simply Level (HMO C-SNP) feature no copays and no coinsurance for primary care, specialist, telehealth, and podiatry visits, though chiropractic services are not covered in practice. Occupational, physical, speech, mental health, and psychiatric therapies require a $15 copay and no coinsurance, while opioid treatment services carry a $50 copay and no coinsurance.
Preventive Services See details
Preventive Services are partially covered by Simply Level (HMO C-SNP) with no copay and no coinsurance for covered services. However, the plan does not cover the Annual Physical Exam, In-Home Safety Assessment, Medical Nutrition Therapy, post-discharge medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, or counseling services.
Hearing Services See details
Simply Level (HMO C-SNP) partially covers hearing services, offering Medicare-covered exams, one routine exam, and one fitting evaluation per year with no copay and no coinsurance. Up to two prescription hearing aids are covered annually with no copay or coinsurance up to a $3,000 maximum benefit, while OTC hearing aids and inner, outer, or over-the-ear prescription models are not covered.
Vision Services See details
Simply Level (HMO C-SNP) provides partially covered vision services with no copay, no coinsurance, and no deductible. Covered benefits include one routine eye exam per year and eyewear up to a $400 annual maximum, though other eye exam services and upgrades are not covered.
Dental Services See details
Simply Level (HMO C-SNP) dental services are partially covered with no copay and no coinsurance, up to a maximum annual benefit of $1,500. Preventive and most comprehensive services are covered, but implant services and orthodontics are not covered.
Home Infusion bundled Services See details
Simply Level (HMO C-SNP) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Under this benefit, Medicare Part B insulin is covered with a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs require a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis services are covered under the Simply Level (HMO C-SNP) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Simply Level (HMO C-SNP) covers medical equipment with no copays for durable medical equipment (DME), prosthetics, medical supplies, and diabetic equipment. DME requires a 0% to 20% coinsurance, prosthetic devices and medical supplies carry a 20% coinsurance, and diabetic equipment is offered with no coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Simply Level (HMO C-SNP) with no coinsurance, though prior authorization and referrals are required. Members pay no copay for lab services and outpatient X-rays, a $0 to $25 copay for diagnostic procedures and tests, and a minimum $0 copay for diagnostic and therapeutic radiological services.
Home Health Services See details
Home health services are covered by Simply Level (HMO C-SNP) with no copay and no coinsurance, though prior authorization and a referral are required.
Cardiac Rehabilitation Services See details
Simply Level (HMO C-SNP) covers some Cardiac Rehabilitation Services with no copay and no coinsurance, but standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered. Prior authorization and a referral are required for any covered services.
Skilled Nursing Facility (SNF) See details
Simply Level (HMO C-SNP) covers skilled nursing facility (SNF) services with no coinsurance and does not require a prior three-day hospital stay, although referrals and prior authorization are needed. There is no copay for days 1 through 20 and a $40 daily copay for days 21 through 100, though additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Simply Level (HMO C-SNP) partially covers other services, offering over-the-counter items and a chronic illness meal benefit with no copay and no coinsurance, while acupuncture is not covered.
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