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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 Orange, Osceola, Seminole. 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 $3200.00 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 Platinum (HMO C-SNP) plan has an enhanced alternative drug benefit. The plan has no deductible. During the initial coverage phase, you will pay varying copays or coinsurance depending on the drug tier and pharmacy. For example, preferred generic drugs and specialty tier drugs have no copay, while standard generic drugs have a $47 copay. After your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Simply Level Platinum (HMO C-SNP) plan offers a variety of benefits with varying costs. Inpatient hospital stays have a $200 copay for days 1-5, with no copay for days 6-90, and outpatient services range from no copay to a $200 copay. Emergency services have a $120 copay, and primary care visits are free. Preventive services, hearing exams, vision exams, eyewear, and dental services are covered with no copay. The plan also covers ambulance services, offering both ground and air ambulance services, and covers durable medical equipment with a coinsurance between 0% and 20%. This plan also offers up to $85 per month for over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital coverage under the Simply Level Platinum (HMO C-SNP) plan includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For days 1-5 of an inpatient hospital stay, the copay is $200, and there is no copay for days 6-90. For Inpatient Hospital-Acute, the plan covers 3 additional days. Some services, such as Non-Medicare-covered Stay for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric, are not covered.
Outpatient Services See details
Outpatient Services includes coverage for all outpatient hospital services, with a copay of $0-$200, and observation services with a $200 copay. The plan also covers Ambulatory Surgical Center (ASC) Services with no copay, Outpatient Substance Abuse Services with a $50 copay, and Outpatient Blood Services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Simply Level Platinum (HMO C-SNP) plan. There is no copay for this benefit, but prior authorization and a doctor referral are required.
Ambulance and Transportation Services See details
The Simply Level Platinum (HMO C-SNP) plan covers ambulance and transportation services. Ground ambulance services have a $250 copay, while air ambulance services have a 20% coinsurance. Transportation services to plan-approved health-related locations are covered with no copay for up to 24 one-way trips per year, but transportation to any health-related location is not covered.
Emergency Services See details
Emergency Services, including Worldwide Emergency Services, are covered by the Simply Level Platinum (HMO C-SNP) plan. Emergency Services have a $120 copay, while Urgently Needed Services have a $25 copay, and there is no coinsurance for either service. Worldwide Emergency Services has a $100,000 maximum plan benefit coverage amount, and a $120 copay for Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation.
Primary Care See details
Primary Care benefits for Simply Level Platinum (HMO C-SNP) include no copay for Primary Care Physician Services, Chiropractic Services, and Additional Telehealth Benefits, and a $20 copay for Physician Specialist Services. Occupational Therapy Services, Individual and Group Sessions for Mental Health and Psychiatric Services, and Physical Therapy and Speech-Language Pathology Services have a $25 copay, while Opioid Treatment Program Services have a $50 copay, and Routine Foot Care has no copay.
Preventive Services See details
Preventive Services are covered, with no copay for Medicare-covered preventive services, Health Education, Personal Emergency Response System (PERS), Fitness Benefit (Memory Fitness), Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), 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. Annual Physical Exams, In-Home Safety Assessment, Medical Nutrition Therapy (MNT), 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, and Counseling Services are not covered.
Hearing Services See details
The Simply Level Platinum (HMO C-SNP) plan covers hearing exams with no copay, as well as routine hearing exams and fitting/evaluation for hearing aids with no copay for one visit per year. Prescription hearing aids are covered up to $1,000 per year, and there is no copay for two visits per year for all types of prescription hearing aids, but prescription hearing aids for the 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. Eye exams have no copay, and routine eye exams are covered once per year. Eyewear, including contact lenses, eyeglasses (lenses and frames), and eyeglass lenses, has no copay, and a combined maximum of $225 per year, however upgrades are not covered.
Dental Services See details
The Simply Level Platinum (HMO C-SNP) plan covers dental services, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatments, and other preventive dental services with no copay. The plan also covers restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics with no copay.
Home Infusion bundled Services See details
The Simply Level Platinum (HMO C-SNP) plan covers Home Infusion bundled Services, including Medicare Part B Insulin Drugs for a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with a coinsurance between 0% and 20%. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered under the Simply Level Platinum (HMO C-SNP) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered by the Simply Level Platinum (HMO C-SNP) plan and includes Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a coinsurance between 0% and 20%, and Prosthetic Devices and Medical Supplies have a 20% coinsurance. Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts have no copay. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with a doctor referral and prior authorization required. Diagnostic Procedures/Tests have a copay between $0 and $200, Lab Services have no copay, Diagnostic Radiological Services have a copay up to $200, Therapeutic Radiological Services have a copay up to $60, 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 the plan does not cover any of the sub-services, including 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's referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Simply Level Platinum (HMO C-SNP) plan, but require prior authorization and a doctor's referral. 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 Level Platinum (HMO C-SNP) plan covers over-the-counter items and meal benefits with no copay, and 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. This plan offers a maximum of $85 per month for over-the-counter items.
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