Aetna Medicare Select Plan (HMO)
Aetna Medicare Select Plan (HMO) H0523-022 Plan Details
Aetna Medicare Select Plan (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H0523-022
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$0.00
Monthly Premium
Aetna Medicare Select Plan (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H0523-022
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Aetna Medicare Select Plan (HMO) H0523-022 Plan Details
Aetna Medicare Select Plan (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H0523-022
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
$0.00
Monthly Premium
California Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $2000 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | $0 |
| Specialty Doctor Visit | $0 |
| Inpatient Hospital Care | $0 per stay |
| Urgent Care | Copayment for Urgent Care $65.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $125.00 |
| Emergency Room Visit | $125 If you are admitted to the hospital within 0 hours your cost share may be waived, for more information see the Evidence of Coverage |
| Ambulance Transportation | $275 |
Health Care Services and Medical Supplies
Aetna Medicare Select Plan (HMO) 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 $20.00 Prior Authorization Required for Chiropractic Services Referral Required for Chiropractic Services Prior authorization required |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | 0% - 20% Higher cost-share applies to non-OneTouch/LifeScan diabetic supplies. |
| Durable Medical Eqipment (DME) | 0% - 20% for each Medicare-covered durable medical equipment item | 0% for continuous glucose meters | 20% for all other Medicare-covered DME items |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Lab Services: Lab Services: $0 in-network, for more information see Evidence of Coverage Diagnostic Procedures: Diagnostic Procedures/Tests: $0 in-network, for more information see Evidence of Coverage Imaging: Xray: $0 in-network | CT Scans: $60 in-network | Diagnostic Radiology other than CT Scans: $60 in-network | Diagnostic Radiology Mammogram: $0 in-network, for more information see Evidence of Coverage |
| Home Health Care | $0 |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $0.00 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required |
| Mental Health Outpatient Care | Mental Health: Group Sessions: $40 in-network| Individual Sessions: $40 in-network, for more information see Evidence of Coverage |Psychiatric Services: Group Sessions: $40 in-network| Individual Sessions: $40 in-network, for more information see Evidence of Coverage |
| Outpatient Services / Surgery | Ambulatory Surgical Center: $0 in network for preventive and diagnostic colonoscopy | $0 All other in network ASC services, for more information see Evidence of Coverage |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $0.00 Referral Required for Podiatry Services |
| Skilled Nursing Facility Care | $0 per day, days 1-20 $188 per day, days 21-100 in-network, 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. You will be reimbursed for covered services up to the benefit amount.|Preventive dental services: |Oral exams: $0 copay |Bitewing x-rays: $0 copay |Cleanings: $0 copay |Fluoride treatment: $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|$750 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 | In-Network:|Eye Exams:|Copayment for Medicare Covered Benefits $0|Copayment for Routine Eye Exams $0 |(Maximum one exam every year)|Eyewear:|Copayment for Medicare Covered Benefits $0|Copayment for Contacts $0|Copayment for Eyeglasses $0|Copayment for Eyeglass Frames $0|Copayment for Eyeglass Lenses $0|Copayment for Upgrades $0|Maximum Plan Allowance for all Non-Medicare covered Eyewear $225 reimbursement every year. For more information, see the 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|Referral Required for Hearing Exams|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)|$500 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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