Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H3288-034-000
Plan Organization Aetna Medicare
Plan Type Local PPO *
Plan Name Aetna Medicare Basics Plan (PPO)
Drugs Covered No
Doctors Choice Any Doctor
Overall Star Rating Plan too new to be measured
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $5900.00
Formulary Website Formulary Link

Medicare Advantage Plan Health Benefits


Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services Yes In-Network Yes No $0 copay
Non-routine services Yes In-Network Yes No $0 copay
Periodontics Yes In-Network Yes No $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Yes In-Network Yes No $0 copay
Extractions Yes In-Network Yes No $0 copay
Restorative services Yes Out-of-Network Yes No $0 copay
Endodontics Yes In-Network Yes No $0 copay
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - In-Network Yes No $5-150
Outpatient x-rays - In-Network Yes No $5-39
Diagnostic tests and procedures - Out-of-Network Yes No 35%
Lab services - In-Network Yes No $5-20
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $250
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $250 annual deductible
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Hearing aids - inner ear No - - - Not covered
Fitting/evaluation No - - - Not covered
Hearing exam - In-Network No No $25
Hearing aids - outer ear No - - - Not covered
Hearing aids - over the ear No - - - Not covered
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 35% per stay
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - In-Network Yes - 0-20% per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 35% per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 35% per item
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient group therapy visit - Out-of-Network Yes No 35%
Outpatient group therapy visit with a psychiatrist - In-Network Yes No $25
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes No 35%
Inpatient hospital - psychiatric - In-Network Yes No $295 per day for days 1 through 5 $0 per day for days 6 through 90
Outpatient individual therapy visit - Out-of-Network Yes No 35%
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network Yes No $25-275 per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Oral exam Yes In-Network No No $0 copay
Cleaning Yes In-Network No No $0 copay
Dental x-ray(s) Yes Out-of-Network No No $0 copay
Fluoride treatment Yes In-Network No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network Yes No 35%
Physical therapy and speech and language therapy visit - In-Network Yes No $20
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Eyeglass lenses Yes Out-of-Network No No $0 copay
Eyeglasses (frames and lenses) Yes Out-of-Network No No $0 copay
Other No Out-of-Network No No $0 copay
Upgrades Yes Out-of-Network No No $0 copay
Contact lenses Yes Out-of-Network No No $0 copay
Eyeglass frames Yes Out-of-Network No No $0 copay
Routine eye exam Yes Out-of-Network No No $0 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Specialist - Out-of-Network No No 35% per visit
Primary - In-Network - - $5 per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 per visit (always covered)
Urgent care - - - - $5-25 per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network No No 35%
Routine foot care - - - - Not covered
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $10,000 In and Out-of-network $5,900 In-network
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 35%
Other Part B drugs - Out-of-Network Yes - 35%
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 35% per stay
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Appling County, Georgia, Baker County, Georgia, Baldwin County, Georgia, Banks County, Georgia, Barrow County, Georgia, Bartow County, Georgia, Bibb County, Georgia, Bryan County, Georgia, Burke County, Georgia, Butts County, Georgia, Camden County, Georgia, Catoosa County, Georgia, Chatham County, Georgia, Chattahoochee County, Georgia, Chattooga County, Georgia, Cherokee County, Georgia, Clarke County, Georgia, Clay County, Georgia, Clayton County, Georgia, Cobb County, Georgia, Coffee County, Georgia, Colquitt County, Georgia, Columbia County, Georgia, Coweta County, Georgia, Crawford County, Georgia, Crisp County, Georgia, Dawson County, Georgia, Dekalb County, Georgia, Dooly County, Georgia, Dougherty County, Georgia, Douglas County, Georgia, Effingham County, Georgia, Elbert County, Georgia, Emanuel County, Georgia, Evans County, Georgia, Fannin County, Georgia, Fayette County, Georgia, Floyd County, Georgia, Forsyth County, Georgia, Franklin County, Georgia, Fulton County, Georgia, Gilmer County, Georgia, Glynn County, Georgia, Gwinnett County, Georgia, Habersham County, Georgia, Hall County, Georgia, Hancock County, Georgia, Haralson County, Georgia, Harris County, Georgia, Hart County, Georgia, Heard County, Georgia, Henry County, Georgia, Houston County, Georgia, Irwin County, Georgia, Jackson County, Georgia, Jasper County, Georgia, Jefferson County, Georgia, Johnson County, Georgia, Jones County, Georgia, Lamar County, Georgia, Laurens County, Georgia, Lee County, Georgia, Liberty County, Georgia, Lincoln County, Georgia, Macon County, Georgia, Madison County, Georgia, Marion County, Georgia, Mcduffie County, Georgia, Mcintosh County, Georgia, Meriwether County, Georgia, Monroe County, Georgia, Morgan County, Georgia, Murray County, Georgia, Muscogee County, Georgia, Newton County, Georgia, Oconee County, Georgia, Oglethorpe County, Georgia, Paulding County, Georgia, Peach County, Georgia, Pickens County, Georgia, Pierce County, Georgia, Pike County, Georgia, Polk County, Georgia, Quitman County, Georgia, Randolph County, Georgia, Richmond County, Georgia, Rockdale County, Georgia, Schley County, Georgia, Screven County, Georgia, Spalding County, Georgia, Stephens County, Georgia, Stewart County, Georgia, Sumter County, Georgia, Tattnall County, Georgia, Taylor County, Georgia, Terrell County, Georgia, Tift County, Georgia, Toombs County, Georgia, Towns County, Georgia, Treutlen County, Georgia, Troup County, Georgia, Turner County, Georgia, Twiggs County, Georgia, Union County, Georgia, Upson County, Georgia, Walton County, Georgia, Ware County, Georgia, Warren County, Georgia, Washington County, Georgia, Wayne County, Georgia, White County, Georgia, Worth County, Georgia

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