Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H3931-095-000
Plan Organization Aetna Medicare
Plan Type Local HMO
Plan Name Aetna Medicare Standard Plan (HMO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors for Most Services
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating 3.5 Stars
Plan Cost Sharing
Premium $58.00
Total Premium (Includes Part B) $193.50
Monthly Part C Premium $33.50
Monthly Part D Basic Premium $24.50
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $24.50
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $6.10
Monthly Part D Premium 50% Assistance $12.20
Monthly Part D Premium 25% Assistance $18.40
Part D Drug Deductible $0.00
Part D Initial Coverage Limit $4020.00
Part D Catastrophic Coverage Threshold $6350.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $6700.00
Gap Coverage Yes
Formulary Website Formulary Link

Medicare Advantage Plan Health Benefits


Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services No - - - Not covered
Restorative services No - - - Not covered
Endodontics No - - - Not covered
Extractions No - - - Not covered
Prosthodontics, other oral/maxillofacial surgery, other services No - - - Not covered
Non-routine services No - - - Not covered
Periodontics No - - - Not covered
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - - Yes No $150
Lab services - - Yes Yes $0-40
Diagnostic tests and procedures - - Yes Yes $40
Outpatient x-rays - - Yes No $45
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Specialist - - No Yes $50 per visit
Primary - - - - $0 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $225
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $325 per day for days 1 through 6 $0 per day for days 7 through 90
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Prosthetics (e.g., braces, artificial limbs) - - Yes - 20% per item
Durable medical equipment (e.g., wheelchairs, oxygen) - - Yes - 20% per item
Diabetes supplies - - Yes - 0-20% per item
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient individual therapy visit with a psychiatrist - - Yes No $40
Inpatient hospital - psychiatric - - Yes No $318 per day for days 1 through 5 $0 per day for days 6 through 90
Outpatient individual therapy visit - - Yes No $40
Outpatient group therapy visit with a psychiatrist - - Yes No $40
Outpatient group therapy visit - - Yes No $40
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses No - - - Not covered
Eyeglass frames No - - - Not covered
Eyeglass lenses No - - - Not covered
Eyeglasses (frames and lenses) No - - - Not covered
Upgrades - - - - Not covered
Other No - No No $50
Routine eye exam Yes - No No $0 copay
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
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Routine foot care - - - - Not covered
Foot exams and treatment - - No Yes $50
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - - Yes Yes $40
Physical therapy and speech and language therapy visit - - Yes Yes $40
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Urgent care - - - - $0-65 per visit (always covered)
Emergency - - - - $90 per visit (always covered)
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Hearing aids - inner ear No - - - Not covered
Fitting/evaluation Yes - No Yes $50
Hearing aids - outer ear No - - - Not covered
Hearing aids - over the ear No - - - Not covered
Hearing exam - - No Yes $50
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $6,700 In-network
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - - Yes - 20%
Other Part B drugs - - Yes - 20%
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning No - - - Not covered
Dental x-ray(s) No - - - Not covered
Fluoride treatment No - - - Not covered
Oral exam No - - - Not covered
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $0 per day for days 1 through 20 $178 per day for days 21 through 100
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
- - - - Yes
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
- - Yes No $50-285 per visit

Medicare Plan Packages


Package #1
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium
Preventive dental Monthly Premium
Package #2
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium
Eyewear Monthly Premium
Hearing aids Monthly Premium
Preventive dental Monthly Premium
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
District Of Columbia County, Washington D.C.

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