Simpra Advantage Assist (PPO I-SNP)
H4091-003 • 2026 • Hale County, AL
Simpra Advantage Assist (PPO I-SNP) H4091-003 • 2026 • Hale County, AL
This Medicare Institutional plan, identified by CMS Plan ID H4091-003, is offered by Simpra Advantage for the 2026 plan year. As a Special Needs Plan (SNP), it is intended for individuals who qualify based on specific eligibility requirements.
Simpra Advantage Assist Overview
Plan Overview for H4091-003-0 | |
|---|---|
| CMS Plan ID: | H4091-003-0 |
| Plan Type: | PPO I-SNP |
| Plan Year: | 2026 |
| Monthly Premium: | $81.00 Plus your Medicare Part B premium. |
| Medical Deductible: | $0.00 |
| Maximum Out-of-Pocket: | $6700.00 (In-Network) |
| Part B Give Back: | Not offered |
| Prescription Drug Coverage: | Enhanced, $150.00 deductible |
| Additional Benefits: | Dental, Vision, Hearing |
| Service Area: | Hale County, AL |
| Enrollment (Nationwide) | 0 beneficiaries |
| Enrollment (CMS – Local) | 0 beneficiaries in Hale County |
| Provided By: | Simpra Advantage |
Plan Overview and Eligibility
- Simpra Advantage Assist is an Institutional Special Needs Plan (I-SNP) for individuals living in an institution or requiring nursing-level care at home.
- This plan accomodates individuals in a long-term care facility. It is also available to people who need the level of care given in a long-term care facility who can remain at home or live in an assisted living facility.
- Eligibility requires Medicare Part A and Part B and residence within the plan’s service area.
- The plan operates on a {network_type} network, which determines how you access covered services.
- Medicare Part D prescription drug coverage is included. The annual Part D deductible is $150.00.
- Care and cost-sharing may be coordinated based on your care environment.
- Extra Help may provide additional assistance with prescription drug costs.
Simpra Advantage Assist operates on a Preferred Provider Organization (PPO) network. Members may access care from in-network or out-of-network providers, with lower out-of-pocket costs when using in-network services. Referrals are generally not required for specialist visits. Emergency services and out-of-area dialysis are covered.
Covered Services and Cost Structure
This section outlines in-network costs for primary care and specialist office visits, along with related preventive services.
| Covered Service | In-Network Cost |
|---|---|
| Primary: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Specialist: | In-network: $30 copay | Out-of-network: $30 copay |
This section outlines in-network costs for preventive and wellness services included in the plan.
| Covered Service | In-Network Cost |
|---|---|
| Annual wellness exam: | Not covered |
| Telehealth benefit: | In-network: $0-$30 copay, 20% coinsurance |
| Routine chiropractic: | Not covered |
| Fitness benefits: | Not covered |
| Health education: | Not covered |
| Counseling services: | Not covered |
| Over-the-counter drug benefits: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Health transportation (non-emergency): | Not covered |
This section outlines in-network costs for diagnostic services, lab tests, x-rays, and other imaging services.
| Covered Service | In-Network Cost |
|---|---|
| Diagnostic radiology services: | In-network: $50 copay | Out-of-network: $50 copay |
| Lab services: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Outpatient x-rays: | In-network: $5 copay | Out-of-network: $5 copay |
| Diagnostic tests and procedures: | In-network: 20% coinsurance | Out-of-network: 20% coinsurance |
This section outlines in-network costs for emergency services, urgent care, ambulance transportation, inpatient hospital stays, and skilled nursing facility care.
| Covered Service | In-Network Cost |
|---|---|
| Emergency room care: | $90 copay |
| Worldwide emergency care: | Not covered |
| Urgent care: | $30 copay |
| Inpatient hospital care: | In-network: | Tier 1 | $175 per day for days 1-6 | $0 per day for days 7-90 | $0 per stay | Out-of-network: | $175 per day for days 1-6 | $0 per day for days 7-90 | $0 per stay |
| Skilled Nursing Facility: | In-network: | Tier 1 | Tier 2 | $0 copay |
| Ground ambulance: | In-network: $150 copay | Out-of-network: 20% coinsurance |
This section outlines in-network costs for mental health services, including outpatient therapy and inpatient psychiatric care.
| Covered Service | In-Network Cost |
|---|---|
| Outpatient individual therapy: | In-network: $30 copay | Out-of-network: $30 copay |
| Outpatient group therapy: | In-network: $30 copay | Out-of-network: $30 copay |
| Inpatient psychiatric hospital care: | In-network: | Tier 1 | $175 per day for days 1-6 | $0 per day for days 7-90 | $0 per stay | Out-of-network: | $175 per day for days 1-6 | $0 per day for days 7-90 | $0 per stay |
This section outlines in-network costs for rehabilitation services, including physical therapy, speech and language therapy, and occupational therapy.
| Covered Service | In-Network Cost |
|---|---|
| Physical therapy and speech and language therapy: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Occupational therapy: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
This section outlines in-network costs for medical equipment and supplies, including diabetes supplies, durable medical equipment, and prosthetics.
| Covered Service | In-Network Cost |
|---|---|
| Diabetes supplies: | In-network: 20% coinsurance | Out-of-network: 20% coinsurance |
| Durable medical equipment: | In-network: 20% coinsurance | Out-of-network: 20% coinsurance |
| Prosthetics: | In-network: 20% coinsurance | Out-of-network: 20% coinsurance |
This section outlines in-network cost sharing for chemotherapy and other Medicare Part B-covered drugs.
| Covered Service | In-Network Cost |
|---|---|
| Chemotherapy: | In-network: 0%-20% coinsurance | Out-of-network: 20% coinsurance |
| Other Part B drugs (Medicare-covered): | In-network: 0%-20% coinsurance | Out-of-network: 20% coinsurance |
This section outlines in-network cost sharing for dental services, including preventive care, exams, x-rays, cleanings, and comprehensive dental procedures.
| Covered Service | In-Network Cost |
|---|---|
| Oral exam: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Dental x-rays: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Cleaning: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Periodontics: | Not covered |
| Endodontics: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Restorative services: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Implant services: | Not covered |
| Orthodontics: | Not covered |
| Oral/Maxillofacial surgery: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
This section outlines in-network cost sharing for vision services, including eye exams, eyeglasses, and contact lenses.
| Covered Service | In-Network Cost |
|---|---|
| Routine eye exam: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Contact lenses: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Eyeglass frames only: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Eyeglass lenses only: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Eyeglasses (frames & lenses): | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Upgrades: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
This section outlines in-network cost sharing for hearing-related services, including exams, fittings, and hearing aids.
| Covered Service | In-Network Cost |
|---|---|
| Hearing exam: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Fitting/evaluation: | Not covered |
| Prescription hearing aids: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| OTC hearing aids: | Not covered |
This section outlines in-network cost sharing for additional and special needs services that may be included in the plan.
| Covered Service | In-Network Cost |
|---|---|
| Adult day health services: | Not covered |
| Home-based palliative care: | Not covered |
| Personal emergency response system: | Not covered |
| Weight management programs: | Not covered |
| Wigs for chemotherapy-related hair loss: | Not covered |
| Alternative therapies: | Not covered |
| Massage therapy: | Not covered |
| Home/bathroom safety devices: | Not covered |
Prescription Drug Plan Costs & Benefits
Prescription Drug Plan Premium
The following table outlines the prescription drug plan premium details of this plan.
| Part D Premium Component | Amount |
|---|---|
| Basic Part D Premium: | $71.00 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $71.00 |
| Low Income Premium Subsidy: | $27.74 |
| Low Income Premium Subsidy CMS Pays: | $27.70 |
| Low Income Subsidy Premium: | $43.30 |
For more information about the Low Income Subsidy, refer to the Social Security Extra Help page.
Drug Plan Deductible
The prescription drug annual deductible with this plan is $150.00. This is the amount you must pay at the pharmacy before Simpra Advantage begins paying its share.
Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and drug plan deductible, Simpra Advantage Assist has costs that you must pay out-of-pocket when you pick up your prescriptions. The following table details those costs by formulary tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $4.00 copay | Coming soon |
| Generic | $15.00 copay | Coming soon |
| Preferred Brand | $45.00 copay | Coming soon |
| Non-Preferred Drug | $95.00 copay | Coming soon |
| Specialty Tier | 31% coinsurance | Coming soon |
| *Deductible does not apply. | ||
Quality Ratings (CMS)
CMS star ratings reflect how well a Medicare plan performs across key quality measures, such as managing chronic conditions, member satisfaction, and customer service. Ratings range from 1 to 5 stars and are updated each year by Medicare.
CMS Star Ratings for Plan H4091-003-0 – 2026
| CMS Measure | Star Rating (out of 5) |
|---|---|
| 2026 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | Not enough data available |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | Not enough data available |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | Not enough data available |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | Not enough data available |
| Drug Safety and Accuracy of Drug Pricing |
Contact Information for Simpra Advantage
| Contact Type | Details |
|---|---|
| Website: | Simpra Advantage Plan Page |
| New Members: | 1-844-637-4770 |
| Existing Members: | 1-844-637-4770 |
| Plan Address: | PO Box 23607 | Tampa, FL 33623 |
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at medicare.gov.
- CMS.gov, Landscape Source Files — Last accessed May 2, 2026
- CMS.gov, Medicare Part C & D Performance — Last accessed May 2, 2026
- CMS.gov, Plan Benefits Package — Last accessed May 2, 2026
- CMS.gov, Monthly Enrollment by Contract/Plan/State/County — Last accessed May 2, 2026
Data sources and methodology documentation.
- Simpra Advantage (official source), http://www.simpra.com — Last accessed April 30, 2026
- CMS.gov, "Institutional Special Needs Plans (I-SNPs)" — Last accessed April 28, 2026
- Medicare.gov, "Understanding Medicare Advantage Plans" — Last accessed April 28, 2026
- AARP.org, "The Big Choice: Original Medicare vs. Medicare Advantage" — Last accessed April 28, 2026
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