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Simply Extra (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Simply Extra (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Simply Extra (HMO) in 2025, please refer to our full plan details page.
Simply Extra (HMO) is a HMO 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 Extra (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Simply Extra (HMO).
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 Extra (HMO), 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 $145.00. 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 Extra (HMO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay a copay for your prescriptions, which varies depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have a $20 copay at preferred and standard pharmacies, and no copay at standard mail pharmacies. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The Simply Extra (HMO) plan offers a variety of health benefits with varying costs. Inpatient hospital stays have a copay, with different amounts based on the type of care and the length of stay. Outpatient services, including those for substance abuse, have copays, while ambulance services have a copay or coinsurance depending on the type of transport. This plan covers many primary care services, preventive services, hearing, vision, and dental services, often with no copay. It also includes benefits for home health, medical equipment, and diagnostic services, often with no copay or coinsurance. The plan also offers over-the-counter items and a meal benefit, both with no copay.
Inpatient Hospital See details
Inpatient Hospital services, including acute and psychiatric care, are covered, but require prior authorization and a doctor's referral. For Inpatient Hospital-Acute and Inpatient Hospital Psychiatric care, you will pay a $200 copay for days 1-5, and no copay for days 6-90; additional days for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services for the Simply Extra (HMO) plan cover outpatient hospital services with a copay between $0 and $200, and observation services with a $200 copay. Ambulatory Surgical Center (ASC) Services have no copay, while outpatient substance abuse services have a $25 copay for both individual and group sessions. Outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Simply Extra (HMO) plan, with a $25 copay. Prior authorization and a doctor referral are required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Simply Extra (HMO) plan, with prior authorization required. Ground ambulance services have a $250 copay, while air ambulance services have 20% coinsurance. Transportation services to a plan-approved health-related location are covered with no copay, with up to 12 one-way trips per year via rideshare, bus/subway, van, or medical transport, but transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered by the Simply Extra (HMO) plan, with a $135 copay and no coinsurance. Urgently Needed Services have a $30 copay and no coinsurance. Worldwide Emergency Services are covered, with a $135 copay for Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation, and a maximum plan benefit coverage of $100,000.
Primary Care See details
The Simply Extra (HMO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, podiatry services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Primary care physician services and chiropractic services have no copay, occupational therapy services, individual and group sessions for mental health and psychiatric services, and opioid treatment program services have a $25 copay, physician specialist services have a $30 copay, physical therapy and speech-language pathology services have a $25 copay, and additional telehealth benefits have no copay. Routine Chiropractic Care is not covered.
Preventive Services See details
Preventive Services are covered by the Simply Extra (HMO) plan, with no copay for Medicare-covered services, Health Education, Fitness Benefit, Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. Annual Physical Exams, 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 Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing Services includes hearing exams with a $25 copay, and prescription hearing aids with a maximum benefit of $500 per year. OTC hearing aids are covered with a maximum benefit of $500 per year.
Vision Services See details
Vision services, including eye exams and eyewear, are covered under the Simply Extra (HMO) plan. Eye exams and eyewear have no copay, and eyewear has a combined maximum benefit of $100 per year.
Dental Services See details
The Simply Extra (HMO) plan covers a variety of dental services. Medicare dental services have no copay, but require prior authorization, and other dental services have a $500 annual maximum. Oral exams and dental x-rays have no copay, with 2 oral exams and 3 dental x-rays covered per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are covered with coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Simply Extra (HMO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
The Simply Extra (HMO) plan covers Durable Medical Equipment (DME) with no copay and a coinsurance between 0% and 20%, but does not cover DME for use outside the home. The plan also covers Prosthetic Devices and Medical Supplies with no copay, and Diabetic Equipment, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts, all with no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including all diagnostic services, diagnostic procedures/tests, and outpatient X-ray services, are covered. Lab services have no copay, while diagnostic procedures/tests have a copay up to $200, and therapeutic radiological services have a copay up to $25 and a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the Simply Extra (HMO) 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 none of the sub-services are covered. Prior authorization and a doctor referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Simply Extra (HMO) plan, with prior authorization and a doctor's referral required. There is no copay for days 1-20, and a $150 copay for days 21-100; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The Simply Extra (HMO) plan offers Over-the-Counter (OTC) Items with no copay, and a monthly maximum plan benefit coverage amount of $47, and it also offers a Meal Benefit with no copay. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, and several other additional services are not covered.
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