Aetna Medicare Dual Select Choice (PPO D-SNP)
Aetna Medicare Dual Select Choice (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H2293-022
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Aetna Medicare Dual Select Choice (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H2293-022
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Georgia Counties Served
Basic Costs and Coverage
Coverage | Cost |
---|---|
Monthly Deductible | $0 |
Out of Pocket Max |
In-Network: $8850 Out-of-Network: N/A |
Initial Coverage Limit | $5030 |
Catastrophic Coverage Limit | $8,000 |
Primary Care Doctor Visit | $0 |
Specialty Doctor Visit | $0 - $15 based on level of Medicaid eligibility. For more information see Evidence of Coverage. |
Inpatient Hospital Care | $0 - $373 per day, days 1-6; $0 per day, days 7-90 based on level of Medicaid eligibility. For more information see Evidence of Coverage. |
Urgent Care | Copayment for Urgent Care $0.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0.00 Maximum Plan Benefit of $250000.00 |
Emergency Room Visit | $0 - $100 based on level of Medicaid eligibility. If you are admitted to the hospital within 24 hours your cost share may be waived. For more information see Evidence of Coverage. |
Ambulance Transportation | $0 - $270 based on level of Medicaid eligibility. For more information see Evidence of Coverage. |
Health Care Services and Medical Supplies
Aetna Medicare Dual Select Choice (PPO D-SNP) 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 $0.00 Copayment for Routine Care $0.00
Prior authorization required Out-of-Network: Copayment for Medicare Covered Chiropractic Services $15.00 Coinsurance for Non-Medicare Covered Chiropractic Services 50% |
Diabetes Supplies, Training, Nutrition Therapy and Monitoring | 0% |
Durable Medical Eqipment (DME) | $0 - 20% based on level of Medicaid eligibility. For more information see Evidence of Coverage. |
Diagnostic Tests, Lab and Radiology Services, and X-Rays | Lab Services: $0, for more information see Evidence of Coverage Diagnostic Procedures: Diagnostic Procedures/Tests: $0 - $95 based on level of Medicaid eligibility| $0 Diagnostic Procedures/Tests: $0, for more information see Evidence of Coverage Imaging: Xray: $0 | CT Scans: $0 - 20% | Diagnostic Radiology other than CT Scans: $0 - 20% based on level of Medicaid eligibility| Diagnostic Radiology Mammogram: 0%. For more information see Evidence of Coverage. |
Home Health Care | $0 in-network | $0 out-of-network |
Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $0.00 per day for days 1 to 3 $0.00 per day for days 4 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: $0.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 |
Mental Health Outpatient Care | $0 - $40 for Mental Health: Group Sessions, $0 - $40 for Mental Health: Individual Sessions based on level of Medicaid eligibility. For more information see Evidence of Coverage |$0 - $40 for Psychiatric Services: Group Sessions, $0 - $40 for Psychiatric Services: Individual Sessions based on level of Medicaid eligibility. For more information see Evidence of Coverage. |
Outpatient Services / Surgery | Ambulatory Surgical Center: $0 in network for preventive and diagnostic colonoscopy |$0 - $300 based on level of Medicaid eligibilityfor all other ASC services, For more information see Evidence of Coverage |
Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Individual or Group Sessions 40% |
Over-the-counter (OTC) Items | Over the counter (OTC) items are covered under the Extra Benefits Card, for more information see Evidence of Coverage|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 $0.00 Copayment for Routine Foot Care $0.00
Out-of-Network: Copayment for Medicare Covered Podiatry Services $15.00 Coinsurance for Non-Medicare Covered Podiatry Services 0% |
Skilled Nursing Facility Care | $0 - $0 per day, days 1-20 $203 per day, days 21-100 based on level of Medicaid eligibility. 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:| $0 copay |Comprehensive dental services:| $0 copay |$2,500 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-$15|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|Out-of-Network:|Eye Exams:
|Copayment for Medicare-Covered Benefits $15|Coinsurance for Routine Eye Exams 0%|Eyewear:|Coinsurance for Medicare-Covered Benefits 40%|Copayment for Non-Medicare covered Benefits $0|Maximum Plan Allowance for all Non-Medicare covered Eyewear $300 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 $0-$15|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) |Out-of-Network:|Copayment for Medicare Covered Hearing Exams $15|Coinsurance for Non-Medicare Covered Hearing Exams 0% |Member must purchase hearing aids through NationsHearing|$1,250 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 |
Prescription Drug Costs and Coverage
The Aetna Medicare Dual Select Choice (PPO D-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $0 per year.
Coverage |
Cost
|
---|---|
Coverage & Cost
|
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Annual Drug Deductible | $0 |
Preferred Generic |
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Generic |
|
Preferred Brand |
|
Non-Preferred Drug |
|
Specialty Tier |
|
Annual Drug Deductible | $0 |
Preferred Generic |
|
Generic |
|
Preferred Brand |
|
Non-Preferred Drug |
|
Specialty Tier |
|
Annual Drug Deductible | $0 |
Preferred Generic |
|
Generic |
|
Preferred Brand |
|
Non-Preferred Drug |
|
Specialty Tier |
|