Aetna Medicare Dual Select Plan (HMO D-SNP)

Aetna Inc.
Aetna Medicare Dual Select Plan (HMO D-SNP) H3239-012 Plan Details
4 out of 5 stars

Aetna Medicare Dual Select Plan (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H3239-012.

$0.00
Monthly Premium

Aetna Medicare Dual Select Plan (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H3239-012.

Aetna Inc.
Aetna Medicare Dual Select Plan (HMO D-SNP) H3239-012 Plan Details
4 out of 5 stars

Aetna Medicare Dual Select Plan (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H3239-012.

$0.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $8300
Out-of-Network: N/A
Initial Coverage Limit $4660
Catastrophic Coverage Limit $7,400
Primary Care Doctor Visit
$0
Specialty Doctor Visit
$0 - $25 based on level of Medicaid eligibility. For more information see Evidence of Coverage.
Inpatient Hospital Care
$0 - $373 per day, days 1-6; $0 per day, days 7-90 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 $95.00
Maximum Plan Benefit of $250000.00
Emergency Room Visit
$0 - $95 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 - $295 based on level of Medicaid eligibility. For more information see Evidence of Coverage.

Health Care Services and Medical Supplies

Aetna Medicare Dual Select Plan (HMO 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
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 - 20% based on level of Medicaid eligibility, 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
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
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 - $300 based on level of Medicaid eligibility/ ASC Screening Colonoscopy Polyp Removal and Post-FIT: $0, 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
Over-the-counter (OTC) Items
$150 quarterly OTC allowance, for more information see Evidence of Coverage
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $0.00
Copayment for Routine Foot Care $25.00
  • Maximum 12 visits every year
Skilled Nursing Facility Care
$0 - $0 per day, days 1-20
$194.50 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
$2,500 maximum benefit for preventive and comprehensive dental services combined - see Evidence of Coverage.

Vision Benefits

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

Coverage Cost
Vision Benefits
$300 every year, see the Evidence of Coverage

Hearing Benefits

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

Coverage Cost
Hearing Benefits
$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

Prescription Drug Costs and Coverage

The Aetna Medicare Dual Select Plan (HMO D-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $0 per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $0
Preferred Generic
  • Standard retail $0.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $0.00
Generic
  • Standard retail $0.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $0.00
Preferred Brand
  • Standard retail $0.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $0.00
Annual Drug Deductible $0
Preferred Generic
  • Standard retail N/A
  • Preferred cost-share mail order N/A
  • Standard mail order N/A
Generic
  • Standard retail N/A
  • Preferred cost-share mail order N/A
  • Standard mail order N/A
Preferred Brand
  • Standard retail N/A
  • Preferred cost-share mail order N/A
  • Standard mail order N/A
Annual Drug Deductible $0
Preferred Generic
  • Standard retail $0.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $0.00
Generic
  • Standard retail $0.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $0.00
Preferred Brand
  • Standard retail $0.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $0.00