Ascension Complete Via Christi Access Plus (PPO)

Ascension Complete Via Christi Access Plus (PPO) H6830-001 Plan Details
Plan too new to be measured

Ascension Complete Via Christi Access Plus (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H6830-001.

$0.00
Monthly Premium

Ascension Complete Via Christi Access Plus (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H6830-001.

Ascension Complete Via Christi Access Plus (PPO) H6830-001 Plan Details
Plan too new to be measured

Ascension Complete Via Christi Access Plus (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H6830-001.

$0.00
Monthly Premium

Kansas Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $3450
Out-of-Network: 5150
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
$0 copay

Out-of-Network
$0 copay
Specialty Doctor Visit
$35

Out-of-Network
$35
Inpatient Hospital Care
$325 copay per day for days 1-6 and a $0 copay per day for days 7-90

Out-of-Network
$325 copay per day for days 1-6 and a $0 copay per day for days 7-90
Urgent Care
$35

Out-of-Network
$35
Emergency Room Visit
$120

Out-of-Network
$120
Ambulance Transportation
$250

Out-of-Network
$250

Health Care Services and Medical Supplies

Ascension Complete Via Christi Access Plus (PPO) 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
Medicare Covered Chiropractic Services: $20 per visit

Out-of-Network
Medicare Covered Chiropractic Services: $20 per visit
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
Diabetes Supplies: $0 / Diabetes Self-Management Training: $0 / Diabetic Therapeutic Shoes or Inserts: 20%

Out-of-Network
Diabetes Supplies: $0 / Diabetes Self-Management Training: $0 / Diabetic Therapeutic Shoes or Inserts: 20%
Durable Medical Eqipment (DME)
20%

Out-of-Network
20%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
X-Ray Services: $0 / Lab Services: $0. $0 for COVID-related testing. For other services, please refer to the Evidence of Coverage for more information.

Out-of-Network
X-Ray Services: $0 / Lab Services: $0. $0 for COVID-related testing. For other services, please refer to the Evidence of Coverage for more information.
Home Health Care
$0 copay

Out-of-Network
$0 copay
Mental Health Inpatient Care
$400 copay per day for days 1-5 and a $0 copay per day for days 6-90

Out-of-Network
$400 copay per day for days 1-5 and a $0 copay per day for days 6-90
Mental Health Outpatient Care
$35 for individual or group

Out-of-Network
$35 for individual or group
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $250.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $120.00 to $250.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $200.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Out-of-Network:

Outpatient Hospital and ASC Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $250.00
Copayment for Medicare Covered Ambulatory Surgical Center Services $0.00 to $250.00
Outpatient Substance Abuse Care
$35 for individual or group

Out-of-Network
$35 for individual or group
Over-the-counter (OTC) Items
$65 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next month/quarter.

Out-of-Network
$65 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next month/quarter.
Podiatry Services
Medicare Covered Podiatry Services: $35 / Routine Podiatry Services: $35 for unlimited visits every year.

Out-of-Network
Medicare Covered Podiatry Services: $35 / Routine Podiatry Services: $35 for unlimited visits every year.
Skilled Nursing Facility Care
$0 copay per day for days 1-20 and a $188 copay per day for days 21-100

Out-of-Network
$0 copay per day for days 1-20 and a $188 copay per day for days 21-100

Dental Benefits

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

Coverage Cost
Dental Care
The dental benefits on this plan include coverage of preventive and comprehensive services up to $3000, including but not limited to cleanings, x-ray(s), oral exams, fluoride treatments, fillings, dentures or a bridge or a crown and a root canal with a $0 member co-pay on preventive and 40% cost share on comprehensive services

Out-of-Network
The dental benefits on this plan include coverage of preventive and comprehensive services up to $1000, including but not limited to cleanings, x-ray(s), oral exams, fluoride treatments, fillings, dentures or a bridge or a crown and a root canal with a 70% member cost-share.

Vision Benefits

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

Coverage Cost
Vision Benefits
The vision benefits on this plan cover routine eye exams and up to $200 for unlimited contacts, glasses, lenses, and/or frames per year

Out-of-Network
The vision benefits on this plan cover routine eye exams and up to $200 with a 40% coinsurance for all services and eyewear received OON, for unlimited contacts, glasses, lenses, and/or frames per year

Hearing Benefits

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

Coverage Cost
Hearing Benefits
The hearing benefits on this plan include, but are not limited to, an annual exam, hearing aid fitting and evaluation, and up to $1000 a year towards hearing aids A maximum of one hearing aid per ear will apply

Out-of-Network
The hearing benefits on this plan include, but are not limited to, an annual exam, hearing aid fitting and evaluation with a 40% coinsurance OON, and up to $1000 a year towards hearing aids A maximum of one hearing aid per ear will apply

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
Most services offered at $0 cost share, please refer to your Evidence of Coverage for more information.

Out-of-Network
Most services offered at $0 cost share, please refer to your Evidence of Coverage for more information.