Aetna Medicare Value Plan (PPO)
Aetna Medicare Value Plan (PPO) H5521-088 Plan Details
Aetna Medicare Value Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-088
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.
$0.00
Monthly Premium
Aetna Medicare Value Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-088
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 Value Plan (PPO) H5521-088 Plan Details
Aetna Medicare Value Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-088
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.
$0.00
Monthly Premium
Ohio Counties Served
Carroll
Jefferson
Crawford
Medina
Hardin
Summit
Trumbull
Cuyahoga
Henry
Seneca
Ottawa
Williams
Huron
Paulding
Lucas
Auglaize
Lake
Sandusky
Erie
Van Wert
Richland
Wyandot
Belmont
Allen
Holmes
Stark
Mercer
Lorain
Geauga
Wayne
Mahoning
Harrison
Ashland
Tuscarawas
Ashtabula
Putnam
Defiance
Hancock
Fulton
Portage
Wood
Columbiana
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $5300 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | $5 in-network | 50% out-of-network |
| Specialty Doctor Visit | $40 in-network | 50% out-of-network |
| Inpatient Hospital Care | $385 per day, days 1-5; $0 per day, days 6-90 in-network | 50% per stay out-of-network |
| Urgent Care | Copayment for Urgent Care $45.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $110.00 |
| Emergency Room Visit | $110 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 | $270 in-network | $270 out-of-network |
Health Care Services and Medical Supplies
Aetna Medicare Value Plan (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 | In-Network: Copayment for Medicare-covered Chiropractic Services $20.00 Prior Authorization Required for Chiropractic Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Chiropractic Services 50% |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | 0% - 20% Higher cost-share applies to non-OneTouch/LifeScan diabetic supplies. |
| Durable Medical Eqipment (DME) | 20% in-network | 50% out-of-network |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Lab Services: Lab Services: $0 in-network| 50% out-of-network, for more information see Evidence of Coverage Diagnostic Procedures: Diagnostic Procedures/Tests: $150 in-network| 50% out-of-network, for more information see Evidence of Coverage Imaging: Xray: $5 for services performed at a non-hospital facility in-network; $110 for services performed at a hospital facility in-network | CT Scans: $35 for services performed at a non-hospital facility in-network; $235 for services performed at a hospital facility in-network | Diagnostic Radiology other than CT Scans: $35 for services performed at a non-hospital facility in-network; $235 for services performed at a hospital facility in-network | Diagnostic Radiology Mammogram: $0 in-network | 50% out-of-network, for more information see Evidence of Coverage |
| Home Health Care | $0 in-network | 50% out-of-network |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $350.00 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 Out-of-Network: Coinsurance for Psychiatric Hospital Services per Stay 50% |
| Mental Health Outpatient Care | Mental Health: Group Sessions: $40 in-network| Individual Sessions: $40 in-network| 50% out-of-network, for more information see Evidence of Coverage |Psychiatric Services: Group Sessions: $40 in-network| Individual Sessions: $40 in-network| 50% out-of-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 | 50% out-of-network, 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 Out-of-Network: Coinsurance for Medicare Covered Individual or Group Sessions 50% |
| Over-the-counter (OTC) Items | In Network: |Over-the-counter (OTC) items:|$150 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.|Medium over-the-counter (OTC) kit of preselected OTC items mailed once a year, for more information see Evidence of Coverage |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $40.00 Copayment for Routine Foot Care $40.00
Out-of-Network: Coinsurance for Medicare Covered Podiatry Services 50% Coinsurance for Non-Medicare Covered Podiatry Services 50% |
| Skilled Nursing Facility Care | $0 per day, days 1-20 $196 per day, days 21-100 in-network| 50% per stay Out-of-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 |Preventive dental services:|Oral exams: $0 copay (four visits every year) |Cleanings: $0 copay (two visits every year) |Bitewing x-rays: $0 copay (one visit every year) |Comprehensive dental services:|Non-routine services: 20%-50% coinsurance (see Evidence of Coverage) |Diagnostic services: $0 copay (see Evidence of Coverage) |Restorative services: 20%-50% coinsurance (see Evidence of Coverage) |Endodontics: 20% coinsurance (see Evidence of Coverage) |Periodontics: 20%-50% coinsurance (see Evidence of Coverage) |Extractions: 20%-50% coinsurance (see Evidence of Coverage) |Prosthodontics and maxillofacial services: 50% coinsurance (see Evidence of Coverage) |Out of Network Dental Coverage|Preventive Dental services:|30% coinsurance |Comprehensive Dental services:|30%-70% coinsurance (see Evidence of Coverage) |$2,000 maximum benefit for comprehensive dental services - 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|Out-of-Network:|Eye Exams:|Coinsurance for Medicare-Covered Benefits 50%|Coinsurance for Routine Eye Exams 50%|Eyewear:|Coinsurance for Medicare-Covered Benefits 50%|Copayment for Non-Medicare covered Benefits $0|Maximum Plan Allowance for all Non-Medicare covered Eyewear $175 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) |Out-of-Network:|Coinsurance for Medicare Covered Hearing Exams 50%|Coinsurance for Non-Medicare Covered Hearing Exams 50% |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 |
