Simplete Riverside 3 (HMO-POS)
H1463 - 034 - 0
(4 / 5)
Simplete Riverside 3 (HMO-POS) is a Medicare Advantage (Part C) Plan by Health Alliance Medicare.
This page features plan details for 2022 Simplete Riverside 3 (HMO-POS) H1463 – 034 – 0 available in Greater Kankakee Area of NE IL/NW IN.
IMPORTANT: This page features the 2022 version of this plan. See the 2024 version using the link below:
No 2024 version found. You can use the location links below to find 2024 plans in your area.
Locations
Simplete Riverside 3 (HMO-POS) is offered in the following locations.
Plan Overview
Simplete Riverside 3 (HMO-POS) offers the following coverage and cost-sharing.
| Insurer: | Health Alliance Medicare |
| Health Plan Deductible: | $0 |
| MOOP: | $4,950.00 |
| Drugs Covered: | Yes |
Ready to sign up for Simplete Riverside 3 (HMO-POS) ?
Premium Breakdown
Simplete Riverside 3 (HMO-POS) has a monthly premium of $29.8. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $170.10 | $40.20 | $29.80 | $0.00 | $240.10 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Simplete Riverside 3 (HMO-POS) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $4,430.00 |
| Catastrophic Coverage Limit: | $7,050.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | Yes |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs. The table below shows how the LIS impacts the Part D premium of this plan.| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $29.80 | $22.50 | $15.30 | $8.00 | $0.70 |
Initial Coverage Phase
After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
60 Day
90 Day
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00, you will pay no more than the amounts below for any drug tier until you reach $7,050.00.
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $2.00 copay | $2.00 copay |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $6.00 copay | $4.00 copay |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Tier | Cost |
|---|---|
| Generic | $4.15 copay or 5% (whichever costs more) |
| Brand-name | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
Simplete Riverside 3 (HMO-POS) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | In-Network: 20% coinsurance (limits may apply) |
| Diagnostic services: | Out-of-Network: 0-50% coinsurance (limits may apply) |
| Endodontics: | In-Network: 20% coinsurance (limits may apply) |
| Endodontics: | Out-of-Network: 0-50% coinsurance (limits may apply) |
| Extractions: | In-Network: 20% coinsurance (limits may apply) |
| Extractions: | Out-of-Network: 0-50% coinsurance (limits may apply) |
| Non-routine services: | In-Network: 20% coinsurance (limits may apply) |
| Non-routine services: | Out-of-Network: 0-50% coinsurance (limits may apply) |
| Periodontics: | In-Network: 20% coinsurance (limits may apply) |
| Periodontics: | Out-of-Network: 0-50% coinsurance (limits may apply) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | In-Network: 20-50% coinsurance (limits may apply) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Out-of-Network: 0-50% coinsurance (limits may apply) |
| Restorative services: | In-Network: 20% coinsurance (limits may apply) |
| Restorative services: | Out-of-Network: 0-50% coinsurance (limits may apply) |
Dental (preventive)
| Cleaning: | In-Network: $0 copay (limits may apply) |
| Cleaning: | Out-of-Network: 0-50% coinsurance (limits may apply) |
| Dental x-ray(s): | In-Network: $0 copay (limits may apply) |
| Dental x-ray(s): | Out-of-Network: 0-50% coinsurance (limits may apply) |
| Fluoride treatment: | In-Network: $0 copay (limits may apply) |
| Fluoride treatment: | Out-of-Network: 0-50% coinsurance (limits may apply) |
| Oral exam: | In-Network: $0 copay (limits may apply) |
| Oral exam: | Out-of-Network: 0-50% coinsurance (limits may apply) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | In-Network: $40-60 copay or 20% coinsurance (authorization required) |
| Diagnostic radiology services (e.g., MRI): | Out-of-Network: 25% coinsurance (authorization required) |
| Diagnostic tests and procedures: | In-Network: $10 copay or 20% coinsurance (authorization required) |
| Diagnostic tests and procedures: | Out-of-Network: 25% coinsurance (authorization required) |
| Lab services: | In-Network: $10 copay or 0-20% coinsurance (authorization required) |
| Lab services: | Out-of-Network: 25% coinsurance (authorization required) |
| Outpatient x-rays: | In-Network: $10 copay or 20% coinsurance (authorization required) |
| Outpatient x-rays: | Out-of-Network: 25% coinsurance (authorization required) |
Doctor visits
| Primary: | In-Network: $5-25 copay per visit |
| Primary: | Out-of-Network: $50 copay per visit |
| Specialist: | In-Network: $10-40 copay per visit |
| Specialist: | Out-of-Network: $60 copay per visit |
Emergency care/Urgent care
| Emergency: | $90 copay per visit (always covered) |
| Urgent care: | $40 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | In-Network: $50 copay |
| Foot exams and treatment: | Out-of-Network: $50 copay |
| Routine foot care: | Not covered |
Ground ambulance
| In-Network: $220 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | In-Network: $0 copay (limits may apply) |
| Hearing aids: | In-Network: $699-999 copay (limits may apply) |
| Hearing exam: | In-Network: $25 copay |
| Hearing exam: | Out-of-Network: $40 copay |
Hospital coverage (inpatient)
| In-Network: Tier 1 $225 per day for days 1 through 8 $0 per day for days 9 through 90 Tier 2 $465 per day for days 1 through 4 $0 per day for days 5 through 90 (authorization required) | |
| Out-of-Network: $600 per day for days 1 through 4 $0 per day for days 5 through 90 (authorization required) |
Hospital coverage (outpatient)
| In-Network: $100 copay or 25% coinsurance per visit (authorization required) | |
| Out-of-Network: 50% coinsurance per visit (authorization required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $6,700 In and Out-of-network $4,950 In-network |
Medical equipment/supplies
| Diabetes supplies: | In-Network: 0-20% coinsurance per item |
| Diabetes supplies: | Out-of-Network: 50% coinsurance per item |
| Durable medical equipment (e.g., wheelchairs, oxygen): | In-Network: 0-20% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | Out-of-Network: 50% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | In-Network: 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | Out-of-Network: 50% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
| Chemotherapy: | Out-of-Network: 50% coinsurance (authorization required) |
| Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | Out-of-Network: 50% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | In-Network: Tier 1 $225 per day for days 1 through 7 $0 per day for days 8 through 90 Tier 2 $425 per day for days 1 through 4 $0 per day for days 5 through 90 (authorization required) |
| Inpatient hospital – psychiatric: | Out-of-Network: $470 per day for days 1 through 4 $0 per day for days 5 through 90 (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | In-Network: $40 copay |
| Outpatient group therapy visit with a psychiatrist: | Out-of-Network: $60 copay |
| Outpatient group therapy visit: | In-Network: $40 copay |
| Outpatient group therapy visit: | Out-of-Network: $50 copay |
| Outpatient individual therapy visit with a psychiatrist: | In-Network: $40 copay |
| Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: $60 copay |
| Outpatient individual therapy visit: | In-Network: $40 copay |
| Outpatient individual therapy visit: | Out-of-Network: $50 copay |
Optional supplemental benefits
| No |
Preventive care
| In-Network: $0 copay | |
| Out-of-Network: $50 copay |
Rehabilitation services
| Occupational therapy visit: | In-Network: $10-40 copay (authorization required) |
| Occupational therapy visit: | Out-of-Network: $50 copay (authorization required) |
| Physical therapy and speech and language therapy visit: | In-Network: $10-40 copay (authorization required) |
| Physical therapy and speech and language therapy visit: | Out-of-Network: $60 copay (authorization required) |
Skilled Nursing Facility
| In-Network: $0 per day for days 1 through 20 $188 per day for days 21 through 100 (authorization required) (referral required) | |
| Out-of-Network: $100 per day for days 1 through 20 $200 per day for days 21 through 100 (authorization required) (referral required) |
Transportation
| Not covered |
Vision
| Contact lenses: | In-Network: $0 copay (limits may apply) |
| Contact lenses: | Out-of-Network: $0 copay (limits may apply) |
| Eyeglass frames: | In-Network: $0 copay (limits may apply) |
| Eyeglass frames: | Out-of-Network: $0 copay (limits may apply) |
| Eyeglass lenses: | In-Network: $0 copay (limits may apply) |
| Eyeglass lenses: | Out-of-Network: $0 copay (limits may apply) |
| Eyeglasses (frames and lenses): | In-Network: $0 copay (limits may apply) |
| Eyeglasses (frames and lenses): | Out-of-Network: $0 copay (limits may apply) |
| Other: | Not covered |
| Routine eye exam: | In-Network: $20 copay (limits may apply) |
| Upgrades: | In-Network: $0 copay (limits may apply) |
| Upgrades: | Out-of-Network: $0 copay (limits may apply) |
Wellness programs (e.g., fitness, nursing hotline)
| Covered |
Ready to sign up for Simplete Riverside 3 (HMO-POS) ?