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Aetna Medicare Dual Select Choice (PPO D-SNP)

Aetna Inc.
Aetna Medicare Dual Select Choice (PPO D-SNP) H5521-465 Plan Details
3.5 out of 5 stars

Aetna Medicare Dual Select Choice (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-465

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$40.10
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Aetna Medicare Dual Select Choice (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-465

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Get Medicare Help
Aetna Inc.
Aetna Medicare Dual Select Choice (PPO D-SNP) H5521-465 Plan Details
3.5 out of 5 stars

Aetna Medicare Dual Select Choice (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-465

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Get Medicare Help
$40.10
Monthly Premium

Mississippi Counties Served

Stone Greene Bolivar Tate Tunica Marshall Leflore Harrison Attala Pike Lamar Coahoma Quitman Sunflower Holmes Hinds Carroll Jones Copiah Sharkey Issaquena Forrest Wayne Jackson Rankin Tallahatchie Yazoo Montgomery Grenada Madison Washington Claiborne Panola Perry Marion Walthall Humphreys Yalobusha Lincoln Desoto Simpson George Warren Hancock Lafayette Monroe Choctaw Lee Amite Calhoun Union Tishomingo Adams Jefferson Tippah Winston Franklin Itawamba Prentiss Alcorn Oktibbeha Chickasaw Clay Noxubee Benton Pearl River Webster Pontotoc Wilkinson Lowndes

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $8850
Out-of-Network: N/A
Initial Coverage Limit $5030
Catastrophic Coverage Limit $8,000
Primary Care Doctor Visit
$0
Specialty Doctor Visit
$0 - $20 based on level of Medicaid eligibility. For more information see Evidence of Coverage.
Inpatient Hospital Care
$0 - $362 per day, days 1-7; $0 per day, days 8-90 based on level of Medicaid eligibility. For more information see Evidence of Coverage.
Urgent Care
Copayment for Urgent Care $0.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0.00
Maximum Plan Benefit of $250000.00
Emergency Room Visit
$0 - $100 based on level of Medicaid eligibility. If you are admitted to the hospital within 24 hours your cost share may be waived. For more information see Evidence of Coverage.
Ambulance Transportation
$0 - $280 based on level of Medicaid eligibility. For more information see Evidence of Coverage.

Health Care Services and Medical Supplies

Aetna Medicare Dual Select Choice (PPO D-SNP) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $0.00
Copayment for Routine Care $0.00
  • Maximum 12 Routine Care every year
Prior Authorization Required for Chiropractic Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Chiropractic Services 20% Coinsurance for Non-Medicare Covered Chiropractic Services 20%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
0%
Durable Medical Eqipment (DME)
$0 - 20% based on level of Medicaid eligibility. For more information see Evidence of Coverage.
Diagnostic Tests, Lab and Radiology Services, and X-Rays
Lab Services: $0, for more information see Evidence of Coverage
Diagnostic Procedures: Diagnostic Procedures/Tests: $0 - $95 based on level of Medicaid eligibility| $0 Diagnostic Procedures/Tests: $0, for more information see Evidence of Coverage
Imaging: Xray: $0 | CT Scans: $0 - 20% | Diagnostic Radiology other than CT Scans: $0 - 20% based on level of Medicaid eligibility| Diagnostic Radiology Mammogram: 0%. For more information see Evidence of Coverage.
Home Health Care
$0 in-network | $0 out-of-network
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$0.00 per day for days 1 to 3
$0.00 per day for days 4 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
$0.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Mental Health Outpatient Care
$0 - $40 for Mental Health:
Group Sessions, $0 - $40 for Mental Health:
Individual Sessions based on level of Medicaid eligibility. For more information see Evidence of Coverage |$0 - $40 for Psychiatric Services:
Group Sessions, $0 - $40 for Psychiatric Services:
Individual Sessions based on level of Medicaid eligibility. For more information see Evidence of Coverage.
Outpatient Services / Surgery
Ambulatory Surgical Center: $0 in network for preventive and diagnostic colonoscopy |$0 - $300 based on level of Medicaid eligibilityfor all other ASC services, For more information see Evidence of Coverage
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Individual or Group Sessions 40%
Over-the-counter (OTC) Items
Over the counter (OTC) items are covered under the Extra Benefits Card, for more information see Evidence of Coverage|Nicotine Replacement Therapy(NRT) offered as a Part C OTC benefit, for more information see Evidence of Coverage
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $0.00
Copayment for Routine Foot Care $0.00
  • Maximum 12 visits every year
Out-of-Network:
Copayment for Medicare Covered Podiatry Services $20.00 Copayment for Non-Medicare Covered Podiatry Services $0.00
Skilled Nursing Facility Care
$0 - $0 per day, days 1-20
$203 per day, days 21-100 based on level of Medicaid eligibility. For more information see Evidence of Coverage.

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In Network Dental Coverage|For covered services: ADA recognized dental services are covered excluding only cosmetic services, those considered medical in nature, and administrative changes.|Preventive dental services: |Oral exams: $0 copay |Cleanings: $0 copay |Fluoride treatment: $0 copay |Bitewing x-rays: $0 copay |Comprehensive dental services:|Non-routine services: $0 copay |Diagnostic services: $0 copay |Restorative services: $0 copay |Endodontics: $0 copay |Periodontics: $0 copay |Extractions: $0 copay |Prosthodontics and maxillofacial services: $0 copay |Out Of Network Dental Coverage|Preventive dental services:| $0 copay |Comprehensive dental services:| $0 copay |$2,550 maximum benefit for preventive and comprehensive dental services combined - see Evidence of Coverage.

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:|Hearing Exams:|Copayment for Medicare Covered Benefits $0-$20|Copayment for Routine hearing Exams $0|(Maximum one exam every year)|Copayment for Fitting/Evaluation for Hearing Aid $0|(Maximum one hearing aid fitting/evaluation every year)|Hearing Aids:|Copayment for Hearing Aids $0|(Maximum two hearing aids every year) |Out-of-Network:|Copayment for Medicare Covered Hearing Exams $20|Coinsurance for Non-Medicare Covered Hearing Exams 0% |Member must purchase hearing aids through NationsHearing|$1,250 per ear every year, for more information see the Evidence of Coverage

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
$0 copay for all preventive services covered under Original Medicare at zero cost sharing
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