Simpra Advantage Assist (PPO I-SNP) Medicare Special Need Plan H4091-003 • 2027
- Monthly Premium
- $90.00Plus Part B premium.
- Medical Deductible
- $0.00
- Maximum Out-of-Pocket
- $6700.00In-network
- Part B Giveback
- Not offered
- Prescription Coverage
- Enhanced, $150.00 deductible
- Additional Benefits
- Dental, Vision, Hearing
- Service Area
- See List
- Total Enrollment
- 0 beneficiaries
Introduction
CMS Plan ID H4091-003 identifies Simpra Advantage Assist, a Medicare Advantage Institutional Special Needs Plan (I-SNP) offered by Simpra Advantage. Its provider network is a Preferred Provider Organization (PPO), and Medicare Part D prescription drug coverage is included. For 2027, the plan has a $90.00 monthly premium, $0.00 medical deductible, and $6700.00 in-network maximum out-of-pocket. The 2027 Part D prescription drug deductible is $150.00.
Enrollment across the plan's service areas totals 0 beneficiaries, according to CMS. Enrollment is limited to beneficiaries who live within the plan's service area: See List.
Eligibility
Simpra Advantage Assist is a Hybrid Institutional (HI-SNP) plan for individuals that require nursing care.
- Special Needs Plan Type
- Institutional Special Needs Plan (I-SNP)
- Medicare Requirement
- Must have Medicare Part A and Part B
- Special Needs Requirement
- This plan accommodates 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.
- Service Area Requirement
- Must live in the plan's service area
- Prescription Drug Coverage
- Medicare Part D prescription drug coverage is included.
Plan Benefits
Simpra Advantage Assist has cost-sharing, meaning there are out-of-pocket costs when receiving covered healthcare services. The tables below detail the most common in-network out-of-pocket expenses for plan H4091-003.
Compare 2027 plan benefits with 2026.
Office Visits
| Covered Service | 2027 | 2026 |
|---|---|---|
| Primary care | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Specialist | In-network: $30 copay Out-of-network: $30 copay |
In-network: $30 copay Out-of-network: $30 copay |
Preventive and Wellness Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Annual wellness exam | Not covered | Not covered |
| Telehealth benefit | In-network: $0-$30 copay, 20% coinsurance | In-network: $0-$30 copay, 20% coinsurance |
| Routine chiropractic | Not covered | Not covered |
| Fitness benefits | Coming soon | Not covered |
| Health education | Not covered | Not covered |
| Counseling services | Not covered | Not covered |
| Over-the-counter drug benefits | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Health transportation (non-emergency) | Coming soon | Not covered |
Diagnostic, Lab, and Imaging Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diagnostic radiology services | In-network: $50 copay Out-of-network: $50 copay |
In-network: $50 copay Out-of-network: $50 copay |
| Lab services | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Outpatient x-rays | In-network: $5 copay Out-of-network: $5 copay |
In-network: $5 copay Out-of-network: $5 copay |
| Diagnostic tests and procedures | In-network: 20% coinsurance Out-of-network: 20% coinsurance |
In-network: 20% coinsurance Out-of-network: 20% coinsurance |
Emergency and Urgent Care Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Emergency room care | $90 copay | $90 copay |
| Worldwide emergency care | Coming soon | Not covered |
| Urgent care | $30 copay | $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 |
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: $0 copay |
In-network: Tier 1 Tier 2 $0 copay |
| Ground ambulance | In-network: $150 copay Out-of-network: 20% coinsurance |
In-network: $150 copay Out-of-network: 20% coinsurance |
Mental Health Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Outpatient individual therapy | In-network: $30 copay Out-of-network: $30 copay |
In-network: $30 copay Out-of-network: $30 copay |
| Outpatient group therapy | In-network: $30 copay Out-of-network: $30 copay |
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 |
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 |
Rehabilitation Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Physical therapy and speech and language therapy | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Occupational therapy | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Medical Equipment and Supplies
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diabetes supplies | In-network: 20% coinsurance Out-of-network: 20% coinsurance |
In-network: 20% coinsurance Out-of-network: 20% coinsurance |
| Durable medical equipment | In-network: 20% coinsurance Out-of-network: 20% coinsurance |
In-network: 20% coinsurance Out-of-network: 20% coinsurance |
| Prosthetics | In-network: 20% coinsurance Out-of-network: 20% coinsurance |
In-network: 20% coinsurance Out-of-network: 20% coinsurance |
Medicare Part B Drugs
| Covered Service | 2027 | 2026 |
|---|---|---|
| Chemotherapy | In-network: 0%-20% coinsurance Out-of-network: 20% coinsurance |
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 |
In-network: 0%-20% coinsurance Out-of-network: 20% coinsurance |
Dental Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Oral exam | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
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 |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Cleaning | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Periodontics | Not covered | Not covered |
| Endodontics | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Restorative services | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Implant services | Not covered | Not covered |
| Orthodontics | Not covered | Not covered |
| Oral/Maxillofacial surgery | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Vision Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Routine eye exam | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Contact lenses | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
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 |
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 |
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 |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Upgrades | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Hearing Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Hearing exam | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Fitting/evaluation | Not covered | Not covered |
| Prescription hearing aids | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| OTC hearing aids | Not covered | Not covered |
Additional and Special Needs Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Adult day health services | Not covered | Not covered |
| Home-based palliative care | Not covered | Not covered |
| Personal emergency response system | Coming soon | Not covered |
| Weight management programs | Not covered | Not covered |
| Wigs for chemotherapy-related hair loss | Coming soon | Not covered |
| Alternative therapies | Not covered | Not covered |
| Massage therapy | Not covered | Not covered |
| Home/bathroom safety devices | Not covered | Not covered |
Certain preventive services are covered 100% by Simpra Advantage Assist as a Part B benefit.
Prescription Drug Coverage
Simpra Advantage Assist includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.
Prescription Drug Plan Premium
The Part D prescription drug plan premium is included in the overall Medicare Advantage plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.
| Part D Premium Component | Amount |
|---|---|
| Basic Part D Premium: | ($65.60) |
| Supplemental Part D Premium: | $81.20 |
| Total Part D Premium: | $15.60 |
| Low-Income Premium Subsidy: | $13.65 |
| Low-Income Premium Subsidy Paid by CMS: | $0.00 |
| Low-Income Subsidy Premium: | $15.60 |
For more details, visit the Social Security Extra Help program .
Prescription Drug Plan Deductible
This plan has a $150.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Simpra Advantage starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, Simpra Advantage Assist may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $0.00 copay | $4.00 copay |
| Generic | $15.00 copay | $15.00 copay |
| Preferred Brand | $45.00 copay | $45.00 copay |
| Non-Preferred Drug | $95.00 copay | $95.00 copay |
| Specialty Tier | 31% coinsurance | 31% coinsurance |
| *Deductible does not apply. | ||
CMS 5-Star Performance Ratings (Contract ID: H4091)
Medicare assigns star ratings to plans based on quality and performance across multiple measures, including customer service, member experience, and health outcomes. Ratings are updated annually by the Centers for Medicare & Medicaid Services (CMS) and are shown on a 1 to 5 star scale, with 5 stars representing the highest quality.
| CMS Measure | Star Rating |
|---|---|
| 2027 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
- Website
- Simpra Advantage Plan Page
- Providers
- Simpra Advantage Providers Page
- Formulary
- Simpra Advantage Formulary Page
- Pharmacy
- Simpra Advantage Pharmacy Page
- New Member Health Plan Help
- (844)637-4770
- New Member Health Plan TTY
- (833)312-0044
- New Member Part D Help
- (844)637-4770
- New Member Part D TTY Users
- (833)312-0044
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.
Plan Availability
Simpra Advantage Assist (H4091-003-0) is available in the following locations (click to open):
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | Last Accessed |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | October 5, 2026 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| Simpra Advantage (official source) | http://www.simpra.com | October 4, 2026 |
| CMS.gov | Institutional Special Needs Plans (I-SNPs) | April 28, 2026 |
| Medicare.gov | Understanding Medicare Advantage Plans | April 28, 2026 |
| NCOA.org | 5 Steps to Choosing the Right Medicare Plan for You | April 28, 2026 |
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