Using your HealthPartners Simplica plan

Simplica is a different approach to health insurance. For in-network care, you won’t have to pay a deductible or coinsurance . Instead, you’ll only pay a simple, straightforward copay amount you look up ahead of time.

Copay amounts are determined by the care you need, the provider you pick, where you’re cared for and your provider’s quality rating. Generally, doctors and clinics with lower copays have higher quality ratings. But remember that no choice is a bad choice: We don’t work with any providers who don’t meet our quality standards.

Simplica puts you in control by:

1. Showing health care prices upfront. When you know the price of your care ahead of time, you can shop around, compare and make more informed choices based on your budget.
2. Assigning lower prices to providers who deliver higher-quality care. When better care simply costs less, you can feel confident that the provider you picked is a good one (especially because we don’t work with any providers who don’t meet our standards).

Simplica is a health insurance plan designed around the idea that shopping for health care should be the same as shopping for anything else: You know the price of something before you decide to buy it, and you know how to get the most value for your money.

Yes. You really can get upfront prices for care at the over 1 million providers in our nationwide network. Simplica puts more power in your hands so you can get the details you need to make the best decisions for your health.

Simplica covers everything a typical health insurance plan covers: preventive care, convenience care and telemedicine services, primary care, specialty care, medical tests, urgent and emergency care, surgeries, hospital stays, medical equipment, and much more.

It depends. Some employers choose to bundle prescription drug coverage with your HealthPartners Simplica plan, while other employers use a different insurance carrier for prescription drug coverage. Review your plan documents to see which case applies to you, or ask your employer if you’re not sure.

• If your Simplica plan includes prescription drug coverage, you’ll pay a copay for your prescriptions, just like everything else. Check your plan documents for more information about covered drugs, copay amounts and any restrictions.
• If your Simplica plan doesn’t include prescription drug coverage, ask your employer for more information about that coverage.

They’re not required, but we strongly encourage downloading the app or creating an online account.

We designed Simplica around an easy-to-use digital health care shopping experience. When you use your HealthPartners app or HealthPartners online account, you can access features that help you get the most out of Simplica’s upfront pricing.

If it’s an emergency, call 911 or go to your nearest hospital emergency room.

If it’s not an emergency, use your HealthPartners app or HealthPartners online account to search for the care you need. We’ll show you providers who can help and what your copay will be at each one. Then, just pick a provider, make an appointment if needed and visit them as usual.

Copay amounts are based on several factors. One of the most important is a provider’s quality rating. These ratings are based on actual data, like how well patients recover, medical safety, how patients feel about their experiences and more.

Generally, copays are lower for doctors and clinics with higher quality ratings. So choosing a higher-rated provider means better care for you at a lower cost. But remember, no choice is a bad choice: We don’t work with providers who don’t meet our quality standards.

If you don’t want to pay your copay at the time of your care, most providers give you the option to be billed later. You might also be able to pay in installments over time. Check with your provider for more information.

In addition to a provider’s quality rating, copay amounts are based in part on the care you need and where you get that care. So if you need to see your doctor for one thing one day and something else the next day, your copay could be different. Seeing the same provider in a clinic or in a hospital could also result in a different copay.

Because of these factors, it’s always best to check your HealthPartners app or HealthPartners online account every time you need care.

Most likely. Our nationwide network includes every provider we work with. In total, that’s over 1 million providers and more than 6,300 hospitals.

Simplica is centered around in-network care, and our nationwide network offers lots of options.

If you choose to get out-of-network care, it’s important to know that we won’t have a contract with your provider. Because of this, we won’t be able to tell you what you’ll pay ahead of time. So like a regular health insurance plan, deductibles and coinsurance amounts will apply (except if you need emergency care).

Review your plan documents for more information about your out-of-network benefits. Note that if you choose to see out-of-network providers, you may also be subject to balance billing .

Yes, your Simplica plan has an in-network out-of-pocket maximum. All copays you pay count toward it.

An out-of-pocket maximum is a safety net that prevents your spending from going over a certain amount. Once you’ve paid enough to reach your plan’s in-network out-of-pocket maximum, your plan will pay 100% of any other covered in-network care for the rest of your plan year. Review your plan documents for more information about your out-of-pocket maximum amount.