Aetna Medicare Select Plan (HMO-POS)
Aetna Medicare Select Plan (HMO-POS) H3931-099 Plan Details
Aetna Medicare Select Plan (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H3931-099
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$0.00
Monthly Premium
Aetna Medicare Select Plan (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H3931-099
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Aetna Medicare Select Plan (HMO-POS) H3931-099 Plan Details
Aetna Medicare Select Plan (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H3931-099
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
$0.00
Monthly Premium
Virginia Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $4000 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | $0 |
| Specialty Doctor Visit | $20 |
| Inpatient Hospital Care | $279 per day, days 1-7; $0 per day, days 8-90 |
| Urgent Care | Copayment for Urgent Care $40.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $120.00 |
| Emergency Room Visit | $120 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 | $290 |
Health Care Services and Medical Supplies
Aetna Medicare Select Plan (HMO-POS) 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 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) | 20% |
| 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 for services provided by your primary care physician in their office in-network; $20 for services performed by a provider other than your primary care physician, for more information see Evidence of Coverage Imaging: Xray: $0 for services provided by your primary care physician in their office in-network; $50 for services performed by a provider other than your primary care physician in-network | CT Scans: $150 in-network | Diagnostic Radiology other than CT Scans: $150 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: $318.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required |
| Mental Health Outpatient Care | Mental Health: Group Sessions: $20 in-network| Individual Sessions: $20 in-network, for more information see Evidence of Coverage |Psychiatric Services: Group Sessions: $20 in-network| Individual Sessions: $20 in-network, for more information see Evidence of Coverage |
| Outpatient Services / Surgery | Ambulatory Surgical Center: $0 in network for preventive and diagnostic colonoscopy | $325 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 |
| Over-the-counter (OTC) Items | In Network: |Over-the-counter (OTC) items:|$210 quarterly amount (allowance) to purchase approved OTC health and wellness products like first aid supplies, cold and allergy medicine, pain relievers and more. Approved items can be purchased online, in store, or by phone. |Be sure to use the full benefit amount quarterly, because any unused amount will not rollover.|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 $40.00 |
| Skilled Nursing Facility Care | $0 per day, days 1-20 $203 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.|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:| 20% coinsurance |Comprehensive dental services:| 20% coinsurance |$2,000 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-$40|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 $350 every year. 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 $40|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)|$2,000 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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