In-network
Inpatient hospital
Medicare-defined coinsurance cost sharing applies (in-network, tier 1).
Out-of-network
Verify in plan documents
Point of service
Not separately reported
● CMS 2027 plan record
Simpra Advantage Dual Care (PPO D-SNP)
Choose and order benefitsSelections are saved only on this device.
Emergency transport
Ambulance
Ground · in-network20% coinsurance
Air · in-network20% coinsurance
Emergency services
Emergency room
20% coinsurance
Waived if admitted within 3 days
Medical maximum
Maximum out-of-pocket
In-network$9,850
Combined in + out$14,800
Skilled care at home
Home health
In-network$0 cost share
Out-of-network$0 cost share
Monthly cost
Premium & giveback
Part C premium$0 / month
Consolidated C + D$13.70 / month
CMS reports no Part B premium reduction for this plan.
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Primary care physician
In: Primary Care Physician Services: $0 cost share · Out: 7a: $0 cost share
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Specialist
In: Physician Specialist Services: 20% coinsurance · Out: 7d: 20% coinsurance
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Preventive care
In: Annual Physical Exam: $0 cost share; Kidney Disease Education Services: 20% coinsurance; Glaucoma Screening: 20% coinsurance; Diabetes Self-Management Training: 20% coinsurance; Digital Rectal Exams: 20% coinsurance; EKG following Welcome Visit: 20% coinsurance · Out: 14b: $0 cost share; 14d: 20% coinsurance; 14e1: 20% coinsurance; 14e2: 20% coinsurance; 14e4: 20% coinsurance; 14e5: 20% coinsurance; 14a: $0 cost share
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Diagnostic procedures & tests
In: Diagnostic Procedures/Tests: 20% coinsurance · Out: 8a1: 20% coinsurance
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Laboratory services
In: Not separately reported · Out: 8a2: $0 cost share
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X-rays & standard imaging
In: Outpatient X-Ray Services: 20% coinsurance · Out: 8b3: 20% coinsurance
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MRI, CT & PET imaging
In: Diagnostic Radiological Services: 20% coinsurance · Out: 8b1: 20% coinsurance
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Urgent care
In: Urgently Needed Services: 20% coinsurance · Out: Not separately reported
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Emergency room
In: 20% coinsurance · Out: Not separately reported
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Ground ambulance
In: 20% coinsurance · Out: 20% coinsurance
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Air ambulance
In: 20% coinsurance · Out: 20% coinsurance
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Outpatient hospital
In: Outpatient Hospital Services: 20% coinsurance; Observation Services: 20% coinsurance · Out: 9a1: 20% coinsurance; 9a2: 20% coinsurance
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Outpatient surgery / ASC
In: Ambulatory Surgical Center (ASC) Services: 20% coinsurance · Out: 9b: 20% coinsurance
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Home health
In: $0 cost share · Out: $0 cost share
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Skilled nursing facility
In: Skilled nursing facility: Tier 1: Medicare-defined coinsurance cost sharing applies (in-network, tier 1). · Out: Skilled nursing facility: Verify in plan documents
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Cardiac & pulmonary rehabilitation
In: Cardiac Rehabilitation Services: 20% coinsurance; Intensive Cardiac Rehabilitation Services: 20% coinsurance; Pulmonary Rehabilitation Services: 20% coinsurance; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable · Out: 3-1: 20% coinsurance; 3-2: 20% coinsurance; 3-3: 20% coinsurance; 3-4: 20% coinsurance
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Occupational therapy
In: Occupational Therapy Services: 20% coinsurance · Out: 7c: 20% coinsurance
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Physical & speech therapy
In: Physical Therapy and Speech-Language Pathology Services: 20% coinsurance · Out: 7i: 20% coinsurance
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Mental health services
In: Partial Hospitalization Program: 20% coinsurance; Individual Sessions for Mental Health Specialty Services: 20% coinsurance; Group Sessions for Mental Health Specialty Services: 20% coinsurance; Individual Sessions for Psychiatric Services: 20% coinsurance; Group Sessions for Psychiatric Services: 20% coinsurance; Inpatient psychiatric hospital: Tier 1: Medicare-defined coinsurance cost sharing applies (in-network, tier 1). · Out: 5a: 20% coinsurance; 7e1: 20% coinsurance; 7e2: 20% coinsurance; 7h1: 20% coinsurance; 7h2: 20% coinsurance; Inpatient psychiatric hospital: Verify in plan documents
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Substance use treatment
In: Intensive Outpatient Program Services: 20% coinsurance; Individual Sessions for Outpatient Substance Abuse: 20% coinsurance; Group Sessions for Outpatient Substance Abuse: 20% coinsurance · Out: 5b: 20% coinsurance; 9c1: 20% coinsurance; 9c2: 20% coinsurance
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Podiatry
In: Podiatry Services: 20% coinsurance; 7f(NMC): Not applicable · Out: 7f: 20% coinsurance
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Chiropractic
In: Chiropractic Services: 20% coinsurance · Out: 7b: 20% coinsurance
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Dental
In: Medicare Dental Services: 20% coinsurance; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 cost share; Dental X-Rays: $0 cost share; Prophylaxis (Cleaning): $0 cost share; Fluoride Treatment: $0 cost share; Restorative Services: $0 cost share; Endodontics: $0 cost share; Prosthodontics, removable: $0 cost share; Maxillofacial Prosthetics: $0 cost share; Prosthodontics, fixed: $0 cost share; Oral and Maxillofacial Surgery: $0 cost share · Out: 16a: 20% coinsurance; 16b1: $0 cost share; 16b2: $0 cost share; 16b4: $0 cost share; 16b5: $0 cost share; 16c1: 20% coinsurance; 16c2: 20% coinsurance; 16c4: 20% coinsurance; 16c5: 20% coinsurance; 16c7: 20% coinsurance; 16c8: 20% coinsurance
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Vision
In: Eye Exams: 20% coinsurance; Eyewear: $0 cost share; Contact Lenses: $0 cost share; Eyeglasses (lenses and frames): $0 cost share; Eyeglass lenses: Not applicable; Eyeglass frames: Not applicable; Upgrades: Not applicable · Out: 17a: 20% coinsurance; 17a1: $0 cost share; 17a2: $0 cost share; 17b: 20% coinsurance; 17b1: $0 cost share; 17b2: $0 cost share
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Hearing
In: Hearing Exams: 20% coinsurance; Fitting/Evaluation for Hearing Aid: Not applicable; Prescription Hearing Aids (all types): $0 cost share; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable; OTC Hearing Aids: $0 cost share · Out: 18a: 20% coinsurance; 18a1: $0 cost share; 18b1: $0 cost share; 18c: $0 cost share
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Transportation
In: 10b(NMC): $0 cost share · Out: Not separately reported
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Fitness & wellness
In: Fitness Benefit: Not applicable · Out: Not separately reported
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Over-the-counter allowance
In: Over-the-Counter (OTC) Items: $0 cost share · Out: 13b: $0 cost share
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Meals
In: Meal Benefit: Not applicable · Out: Not separately reported
Plan details
All plan benefits
No benefits match that search.
Medical care3 benefits
Primary care physician
In-networkPrimary Care Physician Services: $0 cost share
Out-of-network7a: $0 cost share
Specialist
In-networkPhysician Specialist Services: 20% coinsurance
Out-of-network7d: 20% coinsurance
Preventive care
In-networkAnnual Physical Exam: $0 cost share; Kidney Disease Education Services: 20% coinsurance; Glaucoma Screening: 20% coinsurance; Diabetes Self-Management Training: 20% coinsurance; Digital Rectal Exams: 20% coinsurance; EKG following Welcome Visit: 20% coinsurance
Out-of-network14b: $0 cost share; 14d: 20% coinsurance; 14e1: 20% coinsurance; 14e2: 20% coinsurance; 14e4: 20% coinsurance; 14e5: 20% coinsurance; 14a: $0 cost share
Diagnostics & imaging4 benefits
Diagnostic procedures & tests
In-networkDiagnostic Procedures/Tests: 20% coinsurance
Out-of-network8a1: 20% coinsurance
Laboratory services
In-networkNot separately reported
Out-of-network8a2: $0 cost share
X-rays & standard imaging
In-networkOutpatient X-Ray Services: 20% coinsurance
Out-of-network8b3: 20% coinsurance
MRI, CT & PET imaging
In-networkDiagnostic Radiological Services: 20% coinsurance
Out-of-network8b1: 20% coinsurance
Urgent & hospital care6 benefits
Urgent care
In-networkUrgently Needed Services: 20% coinsurance
Out-of-networkNot separately reported
Emergency room
In-network20% coinsurance
Out-of-networkNot separately reported
Ground ambulance
In-network20% coinsurance
Out-of-network20% coinsurance
Air ambulance
In-network20% coinsurance
Out-of-network20% coinsurance
Outpatient hospital
In-networkOutpatient Hospital Services: 20% coinsurance; Observation Services: 20% coinsurance
Out-of-network9a1: 20% coinsurance; 9a2: 20% coinsurance
Outpatient surgery / ASC
In-networkAmbulatory Surgical Center (ASC) Services: 20% coinsurance
Out-of-network9b: 20% coinsurance
Recovery & therapy5 benefits
Home health
In-network$0 cost share
Out-of-network$0 cost share
Skilled nursing facility
In-networkSkilled nursing facility: Tier 1: Medicare-defined coinsurance cost sharing applies (in-network, tier 1).
Out-of-networkSkilled nursing facility: Verify in plan documents
Cardiac & pulmonary rehabilitation
In-networkCardiac Rehabilitation Services: 20% coinsurance; Intensive Cardiac Rehabilitation Services: 20% coinsurance; Pulmonary Rehabilitation Services: 20% coinsurance; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable
Out-of-network3-1: 20% coinsurance; 3-2: 20% coinsurance; 3-3: 20% coinsurance; 3-4: 20% coinsurance
Occupational therapy
In-networkOccupational Therapy Services: 20% coinsurance
Out-of-network7c: 20% coinsurance
Physical & speech therapy
In-networkPhysical Therapy and Speech-Language Pathology Services: 20% coinsurance
Out-of-network7i: 20% coinsurance
Behavioral health2 benefits
Mental health services
In-networkPartial Hospitalization Program: 20% coinsurance; Individual Sessions for Mental Health Specialty Services: 20% coinsurance; Group Sessions for Mental Health Specialty Services: 20% coinsurance; Individual Sessions for Psychiatric Services: 20% coinsurance; Group Sessions for Psychiatric Services: 20% coinsurance; Inpatient psychiatric hospital: Tier 1: Medicare-defined coinsurance cost sharing applies (in-network, tier 1).
Out-of-network5a: 20% coinsurance; 7e1: 20% coinsurance; 7e2: 20% coinsurance; 7h1: 20% coinsurance; 7h2: 20% coinsurance; Inpatient psychiatric hospital: Verify in plan documents
Substance use treatment
In-networkIntensive Outpatient Program Services: 20% coinsurance; Individual Sessions for Outpatient Substance Abuse: 20% coinsurance; Group Sessions for Outpatient Substance Abuse: 20% coinsurance
Out-of-network5b: 20% coinsurance; 9c1: 20% coinsurance; 9c2: 20% coinsurance
Specialty care2 benefits
Podiatry
In-networkPodiatry Services: 20% coinsurance; 7f(NMC): Not applicable
Out-of-network7f: 20% coinsurance
Chiropractic
In-networkChiropractic Services: 20% coinsurance
Out-of-network7b: 20% coinsurance
Supplemental benefits7 benefits
Dental
In-networkMedicare Dental Services: 20% coinsurance; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 cost share; Dental X-Rays: $0 cost share; Prophylaxis (Cleaning): $0 cost share; Fluoride Treatment: $0 cost share; Restorative Services: $0 cost share; Endodontics: $0 cost share; Prosthodontics, removable: $0 cost share; Maxillofacial Prosthetics: $0 cost share; Prosthodontics, fixed: $0 cost share; Oral and Maxillofacial Surgery: $0 cost share
Out-of-network16a: 20% coinsurance; 16b1: $0 cost share; 16b2: $0 cost share; 16b4: $0 cost share; 16b5: $0 cost share; 16c1: 20% coinsurance; 16c2: 20% coinsurance; 16c4: 20% coinsurance; 16c5: 20% coinsurance; 16c7: 20% coinsurance; 16c8: 20% coinsurance
Vision
In-networkEye Exams: 20% coinsurance; Eyewear: $0 cost share; Contact Lenses: $0 cost share; Eyeglasses (lenses and frames): $0 cost share; Eyeglass lenses: Not applicable; Eyeglass frames: Not applicable; Upgrades: Not applicable
Out-of-network17a: 20% coinsurance; 17a1: $0 cost share; 17a2: $0 cost share; 17b: 20% coinsurance; 17b1: $0 cost share; 17b2: $0 cost share
Hearing
In-networkHearing Exams: 20% coinsurance; Fitting/Evaluation for Hearing Aid: Not applicable; Prescription Hearing Aids (all types): $0 cost share; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable; OTC Hearing Aids: $0 cost share
Out-of-network18a: 20% coinsurance; 18a1: $0 cost share; 18b1: $0 cost share; 18c: $0 cost share
Transportation
In-network10b(NMC): $0 cost share
Out-of-networkNot separately reported
Fitness & wellness
Not applicableIn-networkFitness Benefit: Not applicable
Out-of-networkNot separately reported
Over-the-counter allowance
In-networkOver-the-Counter (OTC) Items: $0 cost share
Out-of-network13b: $0 cost share
Meals
Not applicableIn-networkMeal Benefit: Not applicable
Out-of-networkNot separately reported
Plan costs & rulesCoverage overview
Premium & Part B giveback
$0 Part C premium / month · CMS reports no Part B premium reduction for this plan.
Maximum out-of-pocket (MOOP)
In-network$9,850
Combined in + out$14,800
Medical deductibles
In-networkNot reported
Out-of-networkNot reported
Annual health deductible
Not separately reported
Combined network deductible
Not separately reported
Part D premium
$13.70 / month
Network & referrals
Local PPO · Referrals: Not required · Out-of-network coverage: Yes
Prescription drugs0 tiers
Part D deductible
$700 / year
Using this plan
Understand H4091-002-000
Plain-language context built from this plan’s 2027 CMS record. It is a guide to the reported benefits, not a personalized cost estimate.
Plan at a glance
A quick read on this plan
Simpra Advantage Dual Care (PPO D-SNP) is a 2027 Local PPO offered by Simpra Advantage in Alabama statewide. The CMS record indicates out-of-network coverage, although member costs may differ from in-network care. The plan record does not require referrals.
Common benefit costs
What you may pay
These are individual in-network benefit amounts. A real visit may involve more than one separately billed service.
Routine care
- Primary care physician
- Primary Care Physician Services: $0 cost share
- Specialist
- Physician Specialist Services: 20% coinsurance
- Laboratory services
- Not separately reported
Separate visits or services; costs are not added together.
Tests & outpatient care
- Diagnostic procedures & tests
- Diagnostic Procedures/Tests: 20% coinsurance
- MRI, CT & PET imaging
- Diagnostic Radiological Services: 20% coinsurance
- Outpatient hospital
- Outpatient Hospital Services: 20% coinsurance; Observation Services: 20% coinsurance
The service setting and billing details can change what you pay.
Emergency & hospital care
- Emergency room
- 20% coinsurance
Actual costs depend on the care received and plan rules.
Helpful context
Terms worth knowing
Maximum out-of-pocket (MOOP)
This is the most you generally pay during the plan year for covered Part A and Part B medical services under the applicable network limit. Premiums and prescription drug costs generally do not count toward it.
Part B premium reduction (“giveback”)
A giveback may reduce the amount you pay toward Medicare Part B; it is not usually paid to you as cash. The CMS record notes: CMS reports no Part B premium reduction for this plan.
Availability
Who can enroll
- Service area
- Alabama statewide (AL)
- Plan type
- Local PPO
- Special Needs Plan
- Dual-Eligible
- Contract / plan
- H4091-002
- Coverage year
- 2027
This is a Dual-Eligible; enrollment requires the plan's specific eligibility criteria as well as residence in its service area. Confirm eligibility and the exact service area with the plan before enrolling.
Supplemental coverage
Extra benefits reported
Availability is summarized here; allowances, frequency limits, networks, and prior-authorization rules may apply.
DentalMedicare Dental Services: 20% coinsurance; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 cost share; Dental X-Rays: $0 cost share; Prophylaxis (Cleaning): $0 cost share; Fluoride Treatment: $0 cost share; Restorative Services: $0 cost share; Endodontics: $0 cost share; Prosthodontics, removable: $0 cost share; Maxillofacial Prosthetics: $0 cost share; Prosthodontics, fixed: $0 cost share; Oral and Maxillofacial Surgery: $0 cost share
VisionEye Exams: 20% coinsurance; Eyewear: $0 cost share; Contact Lenses: $0 cost share; Eyeglasses (lenses and frames): $0 cost share; Eyeglass lenses: Not applicable; Eyeglass frames: Not applicable; Upgrades: Not applicable
HearingHearing Exams: 20% coinsurance; Fitting/Evaluation for Hearing Aid: Not applicable; Prescription Hearing Aids (all types): $0 cost share; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable; OTC Hearing Aids: $0 cost share
Over-the-counter allowanceOver-the-Counter (OTC) Items: $0 cost share
Transportation10b(NMC): $0 cost share
Plan-specific answers
Frequently asked questions
Where is H4091-002-000 available?
Simpra Advantage Dual Care (PPO D-SNP) is listed for Alabama statewide (AL). This is a Dual-Eligible; enrollment requires the plan's specific eligibility criteria as well as residence in its service area.
What is the in-network maximum out-of-pocket limit for H4091-002-000?
The 2027 CMS record lists an in-network medical maximum out-of-pocket limit of $9,850. Prescription drug spending generally does not count toward this medical limit.
What is the monthly plan premium for H4091-002-000?
The listed consolidated Part C and Part D premium is $13.70 per month. This does not replace the standard Medicare Part B premium.
What does an emergency room visit cost on H4091-002-000?
The plan record lists 20% coinsurance, waived when an admission meets the plan's stated timing rule.
Does H4091-002-000 report extra benefits?
Yes. CMS reports dental, vision, hearing, over-the-counter allowance, transportation. See the detailed benefit rows and official plan documents for limits and conditions.
Source trail
Official CMS, Contract Year 2027
Plan identity and benefits come from CMS PBP data. Benefits and drug cost sharing come from the approved annual PBP tabular extract and its CMS dictionary. Premiums and drug deductibles are cross-checked with the annual Landscape. Geography comes from annual PlanArea and PlanRegionArea records, including exact segments and partial-county or employer/group qualifiers. Quick-reference values should be confirmed in current official plan documents.
Plan context
Where H4091-002-000 fits
- Full CMS plan ID
H4091-002-000- Contract
H4091- Base plan code
H4091-002- Segment
000- Carrier
- Simpra Advantage
- Plan type
- Local PPO
- Service area
- Alabama statewide (AL)
County/service-area foundation
CMS service-area entries
Service areas come from the annual CMS PlanArea and PlanRegionArea tables for this exact contract, plan, and segment. Partial-county and employer/group qualifiers remain part of the coverage area. Regional PPO county entries use the matching annual Landscape expansion of the CMS region.
- Autauga, AL
- Baldwin, AL
- Barbour, AL
- Bibb, AL
- Blount, AL
- Bullock, AL
- Butler, AL
- Calhoun, AL
- Chambers, AL
- Cherokee, AL
- Chilton, AL
- Choctaw, AL
55 additional service-area entries are retained in the data record.
Exact county navigation
Counties with exact segment geography
These links are limited to named counties tied to this exact medical plan segment. Partial-county entries remain labeled for verification.
Show 67 county links
Alabama
- Autauga County, Alabama
- Baldwin County, Alabama
- Barbour County, Alabama
- Bibb County, Alabama
- Blount County, Alabama
- Bullock County, Alabama
- Butler County, Alabama
- Calhoun County, Alabama
- Chambers County, Alabama
- Cherokee County, Alabama
- Chilton County, Alabama
- Choctaw County, Alabama
- Clarke County, Alabama
- Clay County, Alabama
- Cleburne County, Alabama
- Coffee County, Alabama
- Colbert County, Alabama
- Conecuh County, Alabama
- Coosa County, Alabama
- Covington County, Alabama
- Crenshaw County, Alabama
- Cullman County, Alabama
- Dale County, Alabama
- Dallas County, Alabama
- DeKalb County, Alabama
- Elmore County, Alabama
- Escambia County, Alabama
- Etowah County, Alabama
- Fayette County, Alabama
- Franklin County, Alabama
- Geneva County, Alabama
- Greene County, Alabama
- Hale County, Alabama
- Henry County, Alabama
- Houston County, Alabama
- Jackson County, Alabama
- Jefferson County, Alabama
- Lamar County, Alabama
- Lauderdale County, Alabama
- Lawrence County, Alabama
- Lee County, Alabama
- Limestone County, Alabama
- Lowndes County, Alabama
- Macon County, Alabama
- Madison County, Alabama
- Marengo County, Alabama
- Marion County, Alabama
- Marshall County, Alabama
- Mobile County, Alabama
- Monroe County, Alabama
- Montgomery County, Alabama
- Morgan County, Alabama
- Perry County, Alabama
- Pickens County, Alabama
- Pike County, Alabama
- Randolph County, Alabama
- Russell County, Alabama
- Shelby County, Alabama
- St. Clair County, Alabama
- Sumter County, Alabama
- Talladega County, Alabama
- Tallapoosa County, Alabama
- Tuscaloosa County, Alabama
- Walker County, Alabama
- Washington County, Alabama
- Wilcox County, Alabama
- Winston County, Alabama
About this code
What H4091-002-000 identifies
H4091-002-000 is a Contract Year 2027 Medicare plan segment code. Searches written as H4091-002, H4091 002, or the compact full CMS ID H4091002000 refer to this plan or its base plan code.
Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.