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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 Hernando, Hillsborough, Pasco, Pinellas. 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.
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 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 a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, preferred generic drugs and specialty tier drugs have no copay. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered Part D drugs. This plan may offer a reduced premium if you qualify for the low-income subsidy.
Additional Benefits
The Simply Level (HMO C-SNP) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, while outpatient services, partial hospitalization, and many primary care services have no copay. Emergency services and ambulance services have copays or coinsurance, and there is a yearly limit on transportation services. This plan also covers preventive, hearing, vision, and dental services, often with no copay or low copays, but with limitations on some services like eyewear and dental cleanings. Additional benefits include coverage for home infusion, dialysis, medical equipment, and home health services, with varying cost-sharing, and offers additional services like over-the-counter items and meal benefits.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered with prior authorization and a doctor's referral. For days 1-5, the copay is $50, and for days 6-90, there is no copay; additional days, non-Medicare-covered stays, and upgrades are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient hospital services have a copay between $0 and $100, while observation services, ambulatory surgical center services, and outpatient blood services have no copay. Individual and group sessions for outpatient substance abuse have a copay of $50.
Partial Hospitalization See details
Partial Hospitalization is covered under the Simply Level (HMO C-SNP) plan, with a doctor referral and prior authorization required. This benefit has no copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Simply Level (HMO C-SNP) plan. Ground ambulance services have a $200 copay, while air ambulance services have a 20% coinsurance; transportation services to a plan-approved health-related location have no copay, with a limit of 24 one-way trips per year, but transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under 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 plan benefit coverage of $100,000.
Primary Care See details
Primary Care services include no copay for Primary Care Physician Services, and a $0 copay for Chiropractic Services. Occupational Therapy Services have a $15 copay. Physician Specialist Services have no copay. Mental Health Specialty Services, Individual Sessions for Mental Health Specialty Services, and Group Sessions for Mental Health Specialty Services have a $15 copay. Podiatry Services, including Routine Foot Care, have no copay. Other Health Care Professional services have no copay. Psychiatric Services, Individual Sessions for Psychiatric Services, and Group Sessions for Psychiatric Services have a $15 copay. Physical Therapy and Speech-Language Pathology Services have a $15 copay. Additional Telehealth Benefits have no copay. 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, and telemonitoring services are not covered. Medicare-covered 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. Routine hearing exams and fitting/evaluation for hearing aids are covered with no copay. Prescription hearing aids are covered with a maximum benefit of $2000 per year, with no copay for Prescription Hearing Aids (all types), but Prescription Hearing Aids - Inner Ear, Outer Ear, and Over the Ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams and eyewear, with no copay for eye exams, routine eye exams, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames. Eyewear has a combined maximum benefit of $300 per year, and upgrades are not covered.
Dental Services See details
Dental services are covered, including Medicare dental services, oral exams, dental x-rays, prophylaxis (cleaning), restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, and oral and maxillofacial surgery, all with no copay, but fluoride treatment, implant services, and orthodontics are not covered. Oral exams are limited to 2 per year, dental x-rays are limited to 3, and prophylaxis (cleaning) is limited to 2 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay. 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 by the Simply Level (HMO C-SNP) plan, with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment coverage includes Durable Medical Equipment (DME) with a coinsurance of 0% to 20%, and Diabetic Equipment with no copay for Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts. The plan does not cover Durable Medical Equipment for use outside the home. Prosthetic Devices and Medical Supplies have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including all diagnostic services and radiological services, are covered. Diagnostic Procedures/Tests have a copay between $0 and $100, Lab Services have no copay, Diagnostic Radiological Services have a copay between $0 and $100, Therapeutic Radiological Services have a copay between $0 and $60, 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. However, 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 the 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. Prior authorization and a doctor referral are required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered with prior authorization and a doctor referral required. For days 1-20, there is no copay, and for days 21-100, the copay is $150.
Other Services See details
The Simply Level (HMO C-SNP) plan's "Other Services" benefit covers over-the-counter items and meal benefits, each with no copay. However, 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.
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