Simplete Riverside 3 (HMO-POS)

Simplete Riverside 3 (HMO-POS) H1463-034 Plan Details
4 out of 5 stars

Simplete Riverside 3 (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H1463-034.

$70.00
Monthly Premium

Simplete Riverside 3 (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H1463-034.

Simplete Riverside 3 (HMO-POS) H1463-034 Plan Details
4 out of 5 stars

Simplete Riverside 3 (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H1463-034.

$70.00
Monthly Premium

Illinois Counties Served

Indiana Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $4950
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $5.00 to $25.00
POS (Out-of-Network):

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $50.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $10.00 to $40.00
POS (Out-of-Network):

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $60.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services - Tier 1:
$225.00 per day for days 1 to 8
$0.00 per day for days 9 to 90
Prior Authorization Required for Acute Hospital Services - Tier 1

Acute Hospital Services - Tier 2:
$465.00 per day for days 1 to 4
$0.00 per day for days 5 to 90
Prior Authorization Required for Acute Hospital Services - Tier 2
Prior authorization required
Out-of-Network:
$600.00 per day for days 1 to 4
$0.00 per day for days 5 to 90
Urgent Care
Copayment for Urgent Care $40.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $40.00
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Copayment for Worldwide Emergency Transportation $220.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $220.00

Air Ambulance:
Copayment for Air Ambulance Services $220.00

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required

Health Care Services and Medical Supplies

Simplete Riverside 3 (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 $15.00 to $20.00
Prior Authorization Required for Chiropractic Services
Prior authorization required
POS (Out-of-Network):
Copayment for Medicare Covered Chiropractic Services $50.00
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Coinsurance for Medicare-covered Diabetic Supplies 0% to 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
POS (Out-of-Network):
Coinsurance for Medicare Covered Diabetic Supplies and Services 50%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20%
Prior Authorization Required for Durable Medical Equipment
This Plan has preferred Vendors/Manufacturers - Please see Evidence of Coverage
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Durable Medical Equipment 50%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Tier 1:
Copayment for Medicare-covered Diagnostic Procedures/Tests $10.00
Tier 2:
Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20%
Tier 1:
Copayment for Medicare-covered Lab Services $10.00
Tier 2:
Coinsurance for Medicare-covered Lab Services 0% to 20%
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Tier 1:
Copayment for Medicare-covered Diagnostic Radiological Services $40.00 to $60.00
Tier 2:
Coinsurance for Medicare-covered Diagnostic Radiological Services 20%
Tier 1:
Copayment for Medicare-covered Therapeutic Radiological Services $10.00
Tier 2:
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Tier 1:
Copayment for Medicare-covered X-Ray Services $10.00
Tier 2:
Coinsurance for Medicare-covered X-Ray Services 20%
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services

POS (Out-of-Network):

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests
25%
Coinsurance for Medicare Covered Lab Services
25%
Coinsurance for Medicare Covered Diagnostic Radiological Services 25%
Coinsurance for Medicare Covered Therapeutic Radiological Services 25%
Coinsurance for Medicare Covered Outpatient X-Ray Services 25%
Prior authorization required
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
POS (Out-of-Network):
Copayment for Medicare Covered Home Health $50.00
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services - Tier 1:
$225.00 per day for days 1 to 7
$0.00 per day for days 8 to 90
Prior Authorization Required for Psychiatric Hospital Services - Tier 1

Psychiatric Hospital Services - Tier 2:
$425.00 per day for days 1 to 4
$0.00 per day for days 5 to 90
Prior Authorization Required for Psychiatric Hospital Services - Tier 2
Prior authorization required
Out-of-Network:
$470.00 per day for days 1 to 4
$0.00 per day for days 5 to 90
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
POS (Out-of-Network):
Copayment for Medicare Covered Individual Sessions $50.00
Copayment for Medicare Covered Group Sessions $50.00
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Tier 1:
Copayment for Medicare Covered Outpatient Hospital Services $100.00
Tier 2:
Coinsurance for Medicare Covered Outpatient Hospital Services 25%
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Tier 1:
Copayment for Medicare Covered Observation Services - Per stay $55.00
Tier 2:
Coinsurance for Medicare Covered Observation Services - Per stay 25%
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Tier 1:
Copayment for Ambulatory Surgical Center Services $100.00
Tier 2:
Coinsurance for Ambulatory Surgical Center Services 25%
Prior Authorization Required for Ambulatory Surgical Center Services

POS (Out-of-Network):

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 50%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50%
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Coinsurance for Medicare-covered Individual Sessions 20%
Coinsurance for Medicare-covered Group Sessions 20%
POS (Out-of-Network):
Coinsurance for Medicare Covered Individual or Group Sessions 50%
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $50.00
POS (Out-of-Network):
Copayment for Medicare Covered Podiatry Services $50.00
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$188.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Referral Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
$100.00 per day for days 1 to 20
$200.00 per day for days 21 to 100

Dental Benefits

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

Coverage Cost
Dental Care
In-Network:
Up to $1500 yearly allowance with cost share. Please see EOC for coverage.

Preventive Dental:
Copayment for Oral Exams $0.00
Copayment for Prophylaxis (Cleaning) $0.00
Copayment for Fluoride Treatment $0.00
Copayment for Dental X-Rays $0.00

Comprehensive Dental:
Copayment for Medicare-covered Benefits $25.00
Coinsurance for Non-routine Services 20%
Coinsurance for Diagnostic Services 20%
Coinsurance for Restorative Services 20%
Coinsurance for Endodontics 20%
Coinsurance for Periodontics 20%
Coinsurance for Extractions 20%
Coinsurance for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services 20% to 50%

POS (Out-of-Network):

Medicare Covered Dental Services:
Copayment for Medicare Covered Comprehensive Dental $40.00
Non-Medicare Covered Dental Services:
Coinsurance for Non-Medicare Covered Preventive Dental 0% to 50%
Coinsurance for Non-Medicare Covered Comprehensive Dental 0% to 50%
Maximum Plan Benefit of $1500.00 every year

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 $0.00 to $25.00
Copayment for Routine Eye Exams $20.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $25.00
Maximum Plan Allowance of $150.00 every year for all Non-Medicare covered eyewear
POS (Out-of-Network):

Medicare Covered Vision Services:
Copayment for Medicare Covered Eye Exams $40.00
Copayment for Medicare Covered Eyewear $40.00
Non-Medicare Covered Vision Services:
Copayment for Non-Medicare Covered Eyewear $0.00
Maximum Plan Benefit of $150.00 every year

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 $25.00
Copayment for Routine Hearing Exams $45.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 3 visits

Hearing Aids:
Copayment for Hearing Aids $699.00 to $999.00
  • Maximum 2 Hearing Aids every year
Copayment Structure:
Up to two TruHearing-branded hearing aids every year (one per ear per year). Benefit is limited to TruHearing's Advanced and Premium hearing aids, which come in various styles and colors. Premium hearing aids are available in rechargeable style options [for an additional $50 per aid].

[Benefit is combined in and out-of-network.] [TruHearing provider must be used for in-and out-of-network hearing aid benefit.] You must see a TruHearing provider to use this benefit.
Hearing aid purchase includes:
- First year of follow-up provider visits
- 60-day trial period
- 3-year extended warranty
- 80 batteries per aid for non-rechargeable models

Benefit does not include or cover any of the following:
- [Additional cost for optional hearing aid rechargeability]
- Ear molds
- Hearing aid accessories
- Additional provider visits
- Additional batteries, batteries when a rechargeable hearing aid is purchased
- Hearing aids that are not TruHearing

POS (Out-of-Network):

Medicare Covered Hearing Services:
Copayment for Medicare Covered Hearing Exams $40.00

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
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit
    POS (Out-of-Network):

    Medicare-covered Zero Dollar Preventive Services:
    Copayment for Medicare Covered Medicare-covered Preventive Services $50.00