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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 2025, 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 2025.
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 $50.00. 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) plan has an enhanced alternative drug benefit. There is no deductible for prescription drugs. In the initial coverage phase, you will pay a $0 copay for preferred generic and specialty tier drugs at preferred pharmacies, standard pharmacies, and standard mail. You will pay a $15 copay for standard generic drugs, and $55 or $60 for preferred brand drugs. Non-preferred drugs have a 33% coinsurance. Once your total drug costs reach $2,000, you enter the next coverage phase.
Additional Benefits
The Simply Level (HMO C-SNP) plan offers comprehensive coverage with a focus on managing healthcare costs. The plan features no copays for many services, including inpatient hospital stays, outpatient services, primary care physician visits, hearing and vision exams, and most dental services. Additionally, the plan provides coverage for emergency services, ambulance services, and transportation to health-related locations, with varying copays and coinsurance depending on the service. This plan also includes benefits for medical equipment, home health services, and skilled nursing facilities, with no copays for many of these services. Furthermore, the plan offers a monthly allowance for over-the-counter items. However, some services like additional days for inpatient hospital stays, and certain therapies may not be covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both with no copay for Medicare-covered stays. Additional days for Inpatient Hospital-Acute are covered for 3 days with no copay, but Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered under this plan. Outpatient Hospital Services have a copay between $0 and $100, and Observation Services and Ambulatory Surgical Center Services have no copay. Outpatient Substance Abuse services have a $50 copay for both individual and group sessions, and Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Simply Level (HMO C-SNP) plan, requiring prior authorization and a doctor referral. This benefit has no copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services includes coverage for ground ambulance services with a $200 copay, air ambulance services with 20% coinsurance, and transportation services to a plan-approved health-related location with no copay for up to 24 one-way trips per year. Transportation services to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Simply Level (HMO C-SNP) plan. Emergency Services and Worldwide Emergency Coverage have a $135 copay, while Urgently Needed Services has no copay. Worldwide Emergency Services has a maximum benefit coverage of $100,000 and includes coverage for Worldwide Urgent Coverage and Worldwide Emergency Transportation, both with a $135 copay.
Primary Care See details
Primary Care services include no copay for Primary Care Physician Services, and Chiropractic Services, but Routine Chiropractic Care is not covered. Occupational Therapy Services have a $15 copay. Physician Specialist Services have no copay, and Mental Health Specialty Services have a $15 copay for individual and group sessions. Podiatry Services, including Routine Foot Care, have no copay. Other Health Care Professional and Additional Telehealth benefits have no copay, and Psychiatric Services have a $15 copay for individual and group sessions. Physical Therapy and Speech-Language Pathology Services have a $15 copay, and Opioid Treatment Program Services have a $50 copay.
Preventive Services See details
Preventive Services are covered, but annual physical exams, in-home safety assessments, 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, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, and counseling services are not covered. Medicare-covered zero-dollar preventive services, health education, personal emergency response systems, fitness benefits, remote access technologies, home and bathroom safety devices and modifications, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit have no copay.
Hearing Services See details
The Simply Level (HMO C-SNP) plan covers hearing exams with no copay, and routine hearing exams and fitting/evaluation for hearing aids with no copay for one visit every year. Prescription hearing aids are covered up to a maximum of $3000 per year with no copay, while OTC hearing aids are covered up to $500 per year. However, prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision Services include eye exams and eyewear. Eye exams, including routine eye exams, have no copay. Eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, has no copay, and a combined maximum benefit of $400 per year.
Dental Services See details
The Simply Level (HMO C-SNP) plan covers dental services, including oral exams, dental x-rays, other diagnostic services, cleanings, fluoride treatments, other preventative services, and orthodontic services. There is no copay for oral exams, dental x-rays, cleanings, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable), maxillofacial prosthetics, implant services, prosthodontics (fixed), and oral and maxillofacial surgery.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Simply Level (HMO C-SNP) plan. The coinsurance for dialysis services is between 20% and 20%.
Medical Equipment See details
Medical equipment is covered, with no copay for Durable Medical Equipment (DME), and a coinsurance between 0% and 20%. Prosthetics and medical supplies have no copay, and a 20% coinsurance. Diabetic supplies and therapeutic shoes/inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Simply Level (HMO C-SNP) plan. Diagnostic Procedures/Tests have a copay between $0 and $25, Lab Services have no copay, Diagnostic Radiological Services and Therapeutic Radiological Services have a copay up to $50, and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Simply Level (HMO C-SNP) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services. Prior authorization and a doctor referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Simply Level (HMO C-SNP) plan, with a doctor's referral and prior authorization required. For days 1-20, there is no copay, and for days 21-100, the copay is $40.
Other Services See details
The Simply Level (HMO C-SNP) plan's other services include no copay for over-the-counter (OTC) items and meal benefits, while acupuncture, 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. The plan offers a monthly allowance of $90 for OTC items.
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