Simply Level (HMO C-SNP)

4.5 out of 5 stars* for plan year 2023
$0.00 Monthly Premium

Simply Level (HMO C-SNP) is a HMO C-SNP Medicare Advantage (Medicare Part C) plan offered by Simply Healthcare

Plan ID: H5471-073-000

$0.00 Monthly Premium

Florida 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 Florida Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

Coverage Details
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$3,450.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$7,400.00
Primary care doctor visitIn-Network:
$0.00 copay
Specialty doctor visitIn-Network:
$0.00 copay
Inpatient hospital careIn-Network:
Days 1-5: $50.00 per day / Days 6-90: $0.00 per day
Additional Hospital Days: Unlimited additional days
Urgent careUrgent Care: $0.00 copay
Emergency room visitEmergency Care: $75.00 copay
Copay waived if admitted to hospital within 24 Hours
Worldwide Coverage: This plan covers urgent care and emergency services when traveling outside of the United States for less than six months. This benefit is limited to $100,000.00 per year.
Ambulance transportationGround Ambulance: $150.00 copay Per Trip
Air Ambulance: $150.00 copay

Health Care Services and Medical Supplies

Simply Level (HMO C-SNP) covers a range of additional benefits. Learn more about Simply Level (HMO C-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage Details
Chiropractic servicesIn-Network:
Medicare Covered Chiropractic Services: $0.00 copay
Routine Chiropractic Services: $0.00 copay 12 visits each year
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:
Diabetic Supplies: $0.00 copay
Durable medical equipment (DME)In-Network:
0% - 20% coinsurance depending on the equipment
Diagnostic tests, lab and radiology services, and X-raysIn-Network:
Lab Services: $0.00 copay
X-Rays: $0.00 - $100.00 copay
Therapeutic Radiological Services: $0.00 - $60.00 copay
Outpatient Diagnostic Procedures/Tests: $0.00 - $100.00 copay
Diagnostic Radiological Services: $0.00 - $100.00 copay
Home health careIn-Network:
$0.00 copay
Mental health inpatient careIn-Network:
Days 1-5: $50.00 per day / Days 6-90: $0.00 per day
Mental health outpatient careIn-Network:
Individual and Group Sessions: $0.00 copay
Outpatient services/surgeryIn-Network:
Outpatient Hospital - Surgery: $100.00 copay
Observation Services: $0.00 copay
Ambulatory Surgical Center: $0.00 copay
Outpatient substance abuse careIn-Network:
Individual and Group Sessions: $50.00 copay
Over-the-counter itemsThis plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $75 every month. Unused OTC amounts do not roll over from month to month.
Podiatry servicesIn-Network:
Medicare Covered Podiatry Services: $0.00 copay
Routine Foot Care: $0.00 copay
Unlimited routine foot care visits each year.
Skilled Nursing Facility (SNF) careIn-Network:
SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $40.00 per day

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Dental careIn-Network:
Preventive Dental Services: $0.00 copay
This plan covers: 2 Exams, 2 Prophylaxis cleanings, 2 Series of bitewing films, and 1 Panoramic film every year.

Medicare Covered Dental: $0.00 copay
Comprehensive Dental Services: $0.00 copay
This plan covers up to: 2 Amalgam or resin fillings, 6 simple or surgical extractions (in 1 or more visits), 2 crowns, 1 root canal, 2 implants every year, 2 fixed partial dentures (bridges) 1 per arch every 5 years, periodontal scaling and root planing per quadrant every 3 years, 1 set of complete or partial dentures every five years, and 1 denture adjustment/reline every year. Medically necessary surgical procedures including analgesia.

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Vision benefitsIn-Network:
Medicare Covered Eye Exam: $0.00 copay
Routine Eye Exam: $0.00 copay
This plan covers 1 routine eye exam(s) every year.
Medicare Covered Eye Wear: $0.00 copay
Routine Eye Wear: $0.00 copay
This plan covers up to $300.00 for eyeglasses or contact lenses every year.

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Hearing benefitsIn-Network:
Medicare Covered Hearing Exam: $0.00 copay
Routine Hearing Exam: $0.00 copay for routine hearing exam(s). $0.00 copay for hearing aids up to the maximum plan benefit amount.
This plan covers 1 routine hearing exam(s) and hearing aid fitting/evaluation(s) every year. $1,500.00 maximum plan benefit coverage amount applies to prescribed hearing aids covered by the plan every year.

Preventive Services and Health/Wellness Education Programs

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 programsIn-Network:
$0.00 copay for Medicare Covered Preventive Services

When reviewing Florida 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 Florida 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.

Plan Documents

Links to plan documents

Florida Counties Served

Orange Osceola Seminole
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