A non-government entity
Simply Level Platinum (HMO C-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Simply Level Platinum (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 Platinum (HMO C-SNP) in 2025, please refer to our full plan details page.
Simply Level Platinum (HMO C-SNP) is a HMO C-SNP plan offered by Elevance Health, Inc. available for enrollment in 2025 to people living in Select counties in Tampa Area. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Simply Level Platinum (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 Platinum (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 Platinum (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 Platinum (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 $164.90. 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 $2450.00 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:
Sign up for Simply Level Platinum (HMO C-SNP)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Simply Level Platinum (HMO C-SNP) plan has an enhanced alternative drug benefit. There is no deductible for prescription drugs. During the initial coverage phase, you will pay no copay for preferred generic drugs and specialty tier drugs at preferred, standard, and standard mail pharmacies. You will pay a $47 copay for standard generic drugs, $95-$100 for preferred brand drugs, and 33% coinsurance for non-preferred drugs.
Additional Benefits
The Simply Level Platinum (HMO C-SNP) plan offers comprehensive coverage, including inpatient and outpatient hospital services, with varying copays. Emergency services have a $120 copay, and primary care visits have no copay. The plan also includes coverage for hearing, vision, and dental services, with no copays for routine exams and cleanings, as well as coverage for home health and skilled nursing facility services. This plan provides additional benefits like ambulance and transportation services, with a $250 copay for ground ambulance and no copay for transportation to health-related locations. It also covers medical equipment and diagnostic services with varying copays or coinsurance. Additionally, the plan includes benefits like home infusion services, dialysis, and cardiac rehabilitation services.
Inpatient Hospital See details
Inpatient Hospital coverage under the Simply Level Platinum (HMO C-SNP) plan includes a $100 copay for days 1-5 and no copay for days 6-90 for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. Additional days, non-Medicare covered stays, and upgrades for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay between $0 and $200, observation services with a $200 copay, ambulatory surgical center services with no copay, and outpatient substance abuse services with a $50 copay for both individual and group sessions. Outpatient blood services are also covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Simply Level Platinum (HMO C-SNP) plan, with no 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 Level Platinum (HMO C-SNP) plan. 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, up to 24 one-way trips per year using rideshare services, bus/subway, van, or medical transport; transportation to any health-related location is not covered.
Emergency Services See details
Emergency services, including urgent and worldwide emergency services, are covered by the Simply Level Platinum (HMO C-SNP) plan. For emergency services, the copay is $120, and for urgently needed services, the copay is $30; worldwide emergency services have a $120 copay for Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation.
Primary Care See details
The Simply Level Platinum (HMO C-SNP) plan covers primary care physician services and chiropractic services with no copay, but chiropractic services require prior authorization and a doctor referral. Occupational therapy services have a $25 copay, and physician specialist services have a $30 copay. Individual and group sessions for mental health specialty services have a $25 copay, while podiatry services and other health care professional services have no copay. Psychiatric individual and group sessions have a $25 copay, physical therapy and speech-language pathology services have a $25 copay, additional telehealth benefits have no 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, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, and counseling services are not covered. Medicare-covered preventive services require prior authorization and a doctor referral. Health education, Personal Emergency Response System (PERS), fitness benefit, Remote Access Technologies, Home and Bathroom Safety Devices and Modifications, 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 Platinum (HMO C-SNP) plan covers hearing exams with no copay and includes routine hearing exams and fitting/evaluation for hearing aids, both with no copay. Prescription hearing aids are covered with a plan-specified amount up to $1000 per year, but hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision Services includes coverage for eye exams and eyewear, with no copay for eye exams, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames. Eyewear has a combined maximum benefit of $150.00 per year. Upgrades are not covered.
Dental Services See details
The Simply Level Platinum (HMO C-SNP) plan covers dental services, including oral exams, x-rays, and cleanings, with no copay. There is a maximum plan benefit of $1,500 per year for other dental services.
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, 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 Platinum (HMO C-SNP) plan. You will pay 20% coinsurance for this benefit.
Medical Equipment See details
Medical Equipment benefits are covered, including Durable Medical Equipment (DME), with a coinsurance between 0% and 20%, but Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies have a coinsurance, and the plan covers Medicare-covered Prosthetic Devices, and Medicare-covered Medical Supplies with a 20% coinsurance. Diabetic Equipment is covered, and Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including all diagnostic services and radiological services. Diagnostic Procedures/Tests have a copay between $0 and $200, while Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $200, Therapeutic Radiological Services have a copay of at most $50, and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Simply Level Platinum (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 not 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, or Additional Cardiac Rehabilitation Services. A doctor referral and prior authorization are required, and the copay information can be found in the plan details.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by the Simply Level Platinum (HMO C-SNP) plan, but require prior authorization and a doctor referral. For days 1-20, there is no copay, and for days 21-100, the copay is $150.
Other Services See details
Under the Simply Level Platinum (HMO C-SNP) plan, 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. Over-the-counter (OTC) items and meal benefits are covered with no copay.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved