Aetna Medicare Dual Signature Choice (PPO D-SNP)
Aetna Medicare Dual Signature Choice (PPO D-SNP) H5521-472 Plan Details
Aetna Medicare Dual Signature Choice (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-472
HelpAdvisor Editorial Team analysis of data from the 2025 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 Dual Signature Choice (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-472
HelpAdvisor Editorial Team analysis of data from the 2025 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 Signature Choice (PPO D-SNP) H5521-472 Plan Details
Aetna Medicare Dual Signature Choice (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-472
HelpAdvisor Editorial Team analysis of data from the 2025 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
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $9350 Out-of-Network: N/A |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2,000 |
| Primary Care Doctor Visit | $0 in-network|$0 - 40% based on level of Medicaid eligibility out-of-network |
| Specialty Doctor Visit | In-Network|$0||Out-of-Network|$0 - 40% based on level of Medicaid eligibility |
| Inpatient Hospital Care | $0 in-network|$0 - 40% per stay based on level of Medicaid eligibility out-of-network |
| Urgent Care | Copayment for Urgent Care $0 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0 Maximum Plan Benefit of $250,000 |
| Emergency Room Visit | $0 - $110 based on level of Medicaid eligibility. If you are admitted to the hospital within 24 hours your cost share may be waived. |
| Ambulance Transportation | $0 in-network|$0 - 20% based on level of Medicaid eligibility out-of-network |
Health Care Services and Medical Supplies
Aetna Medicare Dual Signature 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 Copayment for Routine Care $0
Out-of-Network: Medicare Covered Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 0% or 20% |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network|0%||Out-of-Network|0% for OneTouch/LifeScan diabetic supplies|$0 - 20% based on level of Medicaid eligibility for other covered diabetic supplies |
| Durable Medical Eqipment (DME) | In-Network|$0||Out-of-Network|$0 - 20% based on level of Medicaid eligibility |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Lab Services: In-Network|$0||Out-of-Network|$0 - 40% based on level of Medicaid eligibility Diagnostic Procedures: In-Network|$0||Out-of-Network|$0 - 40% based on level of Medicaid eligibility Imaging: Xray: $0 in-network|CT Scans: $0 in-network|Diagnostic Radiology other than CT Scans: $0 in-network|Diagnostic Radiology Mammogram: $0 in-network|$0 - 40% based on level of Medicaid eligibility out-of-network |
| Home Health Care | $0 in-network|$0 - 40% based on level of Medicaid eligibility out-of-network |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $0 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Psychiatric Hospital Services: Coinsurance for Psychiatric Hospital per Stay 0% or 40% |
| Mental Health Outpatient Care | In-Network|$0 for Mental Health: Group Sessions|$0 for Mental Health: Individual Sessions|$0 for Psychiatric Services: Group Sessions|$0 for Psychiatric Services: Individual Sessions||Out-of-Network|$0 - 40% for Mental Health Services- Group Sessions based on level of Medicaid eligibility|$0 - 40% for Mental Health Services - Individual Sessions based on level of Medicaid eligibility|$0 - 40% for Psychiatric Services: Group Sessions based on level of Medicaid eligibility|$0 - 40% for Psychiatric Services: Individual Sessions based on level of Medicaid eligibility |
| Outpatient Services / Surgery | Ambulatory Surgical Center: In-Network|$0||Out-of-Network|$0 - 40% based on level of Medicaid eligibility |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $0 Copayment for Medicare-covered Group Sessions $0 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 0% or 40% Coinsurance for Medicare Covered Group Sessions 0% or 40% |
| Over-the-counter (OTC) Items | By qualifying for enrollment in this plan, members receive coverage for approved over-the-counter (OTC) products under the Extra Supports Wallet on the Extra Benefits Card. |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $0 Copayment for Routine Foot Care $0
Out-of-Network: Medicare Covered Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 0% or 40% Non-Medicare Covered Podiatry Services: Copayment for Non-Medicare Covered Podiatry Services $0 |
| Skilled Nursing Facility Care | $0 in-network|$0 - $0 per day, days 1-20 $204 per day, days 21-100 based on level of Medicaid eligibility out-of-network |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network||Preventive dental services:|$0 for oral exams|$0 for cleanings|$0 for fluoride treatment|$0 for x-rays|$0 for other diagnostic dental services|$0 for other preventive dental services||Comprehensive dental services:|$0 for restorative services|$0 for endodontic services|$0 for periodontic services|$0 for removeable prosthodontics|$0 for fixed prosthodontics|$0 for oral and maxillofacial surgery|$0 for adjunctive services||Out-of-Network||Preventive dental services:|$0 for oral exams|$0 for cleanings|$0 for fluoride treatments|$0 for x-rays|$0 for other diagnostic dental services|$0 for other preventive dental services||Comprehensive dental services:|$0 for restorative services|$0 for endodontic services|$0 for periodontic services|$0 for removeable prosthodontics|$0 for fixed prosthodontics|$0 for oral and maxillofacial surgery|$0 for adjunctive services||$3,500 benefit amount (allowance) every year in and out-of-network for covered preventive and comprehensive dental services.||ADA recognized dental services are covered up to the benefit amount excluding implants and related services, orthodontics, cosmetic services, those considered medical in nature, and administrative charges. See EOC for a full list of exclusions. |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network||Eye Exams:|0% for Medicare-covered eye exams|$0 for non-Medicare covered eye exams|(Maximum one non-Medicare covered eye exam every year in or out-of-network)||Eyewear:|0% for Medicare-covered prescription eyewear|$0 for Contacts|$0 for Eyeglasses|$0 for Eyeglass Frames|$0 for Eyeglass Lenses|$0 for Upgrades||Out-of-Network||Eye Exams:|0%-40% based on level of Medicaid eligibility for Medicare-covered eye exams|0% for non-Medicare covered eye exams|(Maximum one non-Medicare covered eye exam every year in or out-of-network)||Eyewear:|0%-40% based on level of Medicaid eligibility for Medicare-covered prescription eyewear|$0 for Contacts|$0 for Eyeglass Frames|$0 for Eyeglass Lenses|$0 for Eyeglass Lenses and Frames|$0 for Upgrades||$350 benefit amount (allowance) every year for non-Medicare covered prescription eyewear. |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network||Hearing Exams:|0% for Medicare-covered hearing exams|$0 for non-Medicare covered hearing exams|(Maximum one non-Medicare covered hearing exam every year in or out-of-network)|$0 for fitting/evaluation for hearing aids|(Maximum one hearing aid fitting/evaluation every year)||Hearing Aids:|$0 for hearing aids|$500 benefit amount (allowance) per ear, every year for hearing aids|(Maximum two hearing aids every year)||Out-of-Network:||Hearing Exams:|0%-20% based on level of Medicaid eligibility for Medicare-covered hearing exams|0% for non-Medicare covered hearing exams|(Maximum one non-Medicare covered hearing exam every year in or out-of-network||Hearing Aids: You must purchase hearing aids through NationsHearing |
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 copay for all preventive services covered under Original Medicare||Out-of-Network|$0 based on level of Medicaid eligibility for all preventive services covered under Original Medicare |
