Ascension Complete Via Christi Access (PPO)

Ascension Complete Via Christi Access (PPO) H6830-002 Plan Details
Plan too new to be measured

Ascension Complete Via Christi Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H6830-002.

$0.00
Monthly Premium

Ascension Complete Via Christi Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H6830-002.

Ascension Complete Via Christi Access (PPO) H6830-002 Plan Details
Plan too new to be measured

Ascension Complete Via Christi Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H6830-002.

$0.00
Monthly Premium

Kansas Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $2900
Out-of-Network: 2900
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
$0 copay

Out-of-Network
$0 copay
Specialty Doctor Visit
20%

Out-of-Network
20%
Inpatient Hospital Care
$525 copay per day for days 1-4 and a $0 copay per day for days 5-90

Out-of-Network
$575 copay per day for days 1-4 and a $0 copay per day for days 5-90
Urgent Care
$40

Out-of-Network
$40
Emergency Room Visit
$120

Out-of-Network
$120
Ambulance Transportation
20%

Out-of-Network
20%

Health Care Services and Medical Supplies

Ascension Complete Via Christi Access (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: 20% / Lab Services: $0 - 20%. $0 for COVID-related testing. For other services, please refer to the Evidence of Coverage for more information.

Out-of-Network
X-Ray Services: 20% / Lab Services: 20%. $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
$575 copay per day for days 1-4 and a $0 copay per day for days 5-90

Out-of-Network
$575 copay per day for days 1-4 and a $0 copay per day for days 5-90
Mental Health Outpatient Care
20% for individual or group

Out-of-Network
20% for individual or group
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 20%
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $120.00
Coinsurance for Medicare Covered Observation Services - Per stay 20%
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Coinsurance for Ambulatory Surgical Center Services 20%
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 20%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 20%
Outpatient Substance Abuse Care
20% for individual or group

Out-of-Network
20% for individual or group
Over-the-counter (OTC) Items
$45 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next month/quarter.

Out-of-Network
$45 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next month/quarter.
Podiatry Services
Medicare Covered Podiatry Services: 20% / Routine Podiatry Services: 20% for unlimited visits every year.

Out-of-Network
Medicare Covered Podiatry Services: 20% / Routine Podiatry Services: 20% 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 $5000, 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.

Out-of-Network
The dental benefits on this plan include coverage of preventive and comprehensive services up to $5000, 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 50% 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 $700 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 $700 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.