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TTY 711
Your Medicare Advantage plan comparison is just one step away!
On the phone
Our licensed insurance agents can help you compare plans and keep your current doctor.
Simplete 3 (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by The Carle Foundation
Plan ID: H1463-025-000
Indiana and Illinois Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about Indiana and Illinois Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
| Coverage | Details |
|---|---|
| Monthly plan premium | $48.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $4,950.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $7,400.00 |
| Primary care doctor visit | POS (Out-of-Network): Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $50.00 |
| Specialty doctor visit | POS (Out-of-Network): Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $50.00 |
| Inpatient hospital care | Out-of-Network: $600.00 per day for days 1 to 4 $0.00 per day for days 5 to 90 |
| Urgent care | Urgent Care: Copayment for Urgent Care $40.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $40.00 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $110.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital Worldwide Coverage: Copayment for Worldwide Emergency Coverage $110.00 Copayment for Worldwide Emergency Transportation $250.00 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $250.00 Air Ambulance: Copayment for Air Ambulance Services $250.00 Please see Evidence of Coverage for Prior Authorization rules |
Simplete 3 (HMO-POS) covers a range of additional benefits. Learn more about Simplete 3 (HMO-POS) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15.00 to $20.00 Prior Authorization Required for Chiropractic Services |
| Diabetes supplies, training, nutrition therapy and monitoring | POS (Out-of-Network): Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies and Services 50% |
| Durable medical equipment (DME) | POS (Out-of-Network): Durable Medical Equipment: Coinsurance for Medicare Covered Durable Medical Equipment 50% |
| Diagnostic tests, lab and radiology services, and X-rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $10.00 to $25.00 Copayment for Medicare-covered Lab Services $0.00 to $25.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $50.00 to $150.00 Copayment for Medicare-covered Therapeutic Radiological Services $10.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $10.00 Coinsurance for Medicare-covered X-Ray Services 20% Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0.00 |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services - Tier 1: $200.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 Prior Authorization Required for Psychiatric Hospital Services - Tier 1 Psychiatric Hospital Services - Tier 2: $250.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 Prior Authorization Required for Psychiatric Hospital Services - Tier 2 |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $200.00 Coinsurance for Medicare Covered Outpatient Hospital Services 25% Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $55.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $200.00 Coinsurance for Ambulatory Surgical Center Services 25% Prior Authorization Required for Ambulatory Surgical Center Services |
| Outpatient substance abuse care | POS (Out-of-Network): Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual or Group Sessions 50% |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $96.00 every month |
| Podiatry services | POS (Out-of-Network): Podiatry Services: Copayment for Medicare Covered Podiatry Services $50.00 |
| Skilled Nursing Facility (SNF) care | Out-of-Network: $100.00 per day for days 1 to 20 $200.00 per day for days 21 to 100 |
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | POS (Out-of-Network): Medicare Covered Dental Services: Copayment for Medicare Covered Comprehensive Dental $25.00 Non-Medicare Covered Dental Services: Coinsurance for Non-Medicare Covered Preventive Dental 0% to 40% Coinsurance for Non-Medicare Covered Comprehensive Dental 0% to 40% Maximum Plan Benefit of $2000.00 every year |
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Vision benefits | POS (Out-of-Network): Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $40.00 Copayment for Medicare Covered Eyewear $40.00 Non-Medicare Covered Vision Services: Copayment for Non-Medicare Covered Eyewear $0.00 Maximum Plan Benefit of $150.00 every year |
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $25.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for Hearing Aids $699.00 to $999.00
*Routine hearing exam cost and hearing aid copayments are not subject to the out-of-pocket maximum. Hearing aid purchase includes: - First year of follow-up provider visits - 60 day trial period - 3 year extended warranty - 80 batteries per aid for non-rechargeable models Benefit does not include or cover any of the following: - Additional cost for optional hearing aid rechargeability - Ear molds - Hearing aid accessories - Additional provider visits - Additional batteries, batteries when a rechargeable hearing aid is purchased - Hearing aids that are not TruHearing-branded hearing aids - Costs associated with loss and damage warranty claims POS (Out-of-Network): Medicare Covered Hearing Services: Copayment for Medicare Covered Hearing Exams $40.00 |
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | POS (Out-of-Network): Medicare-covered Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $50.00 |
When reviewing Indiana and Illinois Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Indiana and Illinois that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
| Links to plan documents |
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