Allina Health Aetna Medicare Elite (PPO)
Allina Health Aetna Medicare Elite (PPO) H3219-004 Plan Details
Allina Health Aetna Medicare Elite (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H3219-004
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.
$134.00
Monthly Premium
Allina Health Aetna Medicare Elite (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H3219-004
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.
Allina Health Aetna Medicare Elite (PPO) H3219-004 Plan Details
Allina Health Aetna Medicare Elite (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H3219-004
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.
$134.00
Monthly Premium
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $3000 Out-of-Network: N/A |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2,000 |
| Primary Care Doctor Visit | $0 in-network|$20 out-of-network |
| Specialty Doctor Visit | In-Network|$15||Out-of-Network|$35 |
| Inpatient Hospital Care | $150 per stay in-network|20% per stay out-of-network |
| Urgent Care | Copayment for Urgent Care $15 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $140 |
| Emergency Room Visit | $140 If you are admitted to the hospital within 0 hours your cost share may be waived |
| Ambulance Transportation | $250 in-network|$250 out-of-network |
Health Care Services and Medical Supplies
Allina Health Aetna Medicare Elite (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 Copayment for Routine Care $20
Out-of-Network: Medicare Covered Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $20 |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network|0% for OneTouch/LifeScan diabetic supplies|20% for other covered diabetic supplies||Out-of-Network|0% for OneTouch/LifeScan diabetic supplies|20% for other covered diabetic supplies |
| Durable Medical Eqipment (DME) | In-Network|0% for continuous glucose monitors|20% for all other Medicare-covered DME items||Out-of-Network|20% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Lab Services: In-Network|$0 ||Out-of-Network|$15 Diagnostic Procedures: In-Network|$0 for certain Medicare-covered diagnostic tests and services including Retinal fundus, Spirometry, Peripheral arterial disease (PAD)||$20 for other diagnostic procedures and tests||Out-of-Network|$25 Imaging: Xray: $15 in-network|$25 out-of-network|CT Scans: $50 in-network|Diagnostic Radiology other than CT Scans: $50 in-network|Diagnostic Radiology Mammogram: $0 in-network|$125 out-of-network |
| Home Health Care | $0 in-network|20% out-of-network |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $150 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Psychiatric Hospital Services: Coinsurance for Psychiatric Hospital per Stay 20% |
| Mental Health Outpatient Care | In-Network|$15 for Mental Health: Group Sessions|$15 for Mental Health: Individual Sessions|$15 for Psychiatric Services: Group Sessions|$15 for Psychiatric Services: Individual Sessions||Out-of-Network|$35 for Mental Health Services- Group Sessions|$35 for Mental Health Services - Individual Sessions|$35 for Psychiatric Services: Group Sessions|$35 for Psychiatric Services: Individual Sessions |
| Outpatient Services / Surgery | Ambulatory Surgical Center: In-Network|$0 for preventive and diagnostic colonoscopy|$125 all other ambulatory surgical center services||Out-of-Network|$300 |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $15 Copayment for Medicare-covered Group Sessions $15 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $35 Copayment for Medicare Covered Group Sessions $35 |
| Over-the-counter (OTC) Items | $75 quarterly benefit amount (allowance) to purchase approved over-the-counter (OTC) health and wellness products. Approved items can be purchased online, in store, or by phone. Unused benefit amounts do not rollover. |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $15 Copayment for Routine Foot Care $15
Out-of-Network: Medicare Covered Podiatry Services: Copayment for Medicare Covered Podiatry Services $35 Non-Medicare Covered Podiatry Services: Copayment for Non-Medicare Covered Podiatry Services $35 |
| Skilled Nursing Facility Care | $0 per day, days 1-20 $214 per day, days 21-35 $0 per day, days 36-100 in-network|20% per stay 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:|20% for oral exams|20% for cleanings|20% for fluoride treatments|20% for x-rays|20% for other diagnostic dental services|20% for other preventive dental services||Comprehensive dental services:|20% for restorative services|20% for endodontic services|20% for periodontic services|20% for removeable prosthodontics|20% for fixed prosthodontics|20% for oral and maxillofacial surgery|20% for adjunctive services||$2,100 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 Diabetic eye exams|$15 for all other 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:|$35 for Medicare-covered eye exams|$35 for non-Medicare covered eye exams|(Maximum one non-Medicare covered eye exam every year in or out-of-network)||Eyewear:|20% 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||$275 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:|$15 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|$1,500 benefit amount (allowance) per ear, every year for hearing aids|(Maximum two hearing aids every year)||Out-of-Network:||Hearing Exams:|$35 for Medicare-covered hearing exams|$35 for 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% for the pneumonia, influenza, Hepatitis B, and Covid-19 vaccines|20% for all other preventive services covered under Original Medicare |
