Allina Health Aetna Medicare Essential (PPO)
Allina Health Aetna Medicare Essential (PPO) H3219-012 Plan Details
Allina Health Aetna Medicare Essential (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H3219-012
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
Allina Health Aetna Medicare Essential (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H3219-012
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 Essential (PPO) H3219-012 Plan Details
Allina Health Aetna Medicare Essential (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H3219-012
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
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $590 |
| Out of Pocket Max |
In-Network: $5500 Out-of-Network: N/A |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2,000 |
| Primary Care Doctor Visit | $0 in-network|50% out-of-network |
| Specialty Doctor Visit | In-Network|$45||Out-of-Network|50% |
| Inpatient Hospital Care | $345 per day, days 1-6; $0 per day, days 7-90 in-network|50% per stay out-of-network |
| Urgent Care | Copayment for Urgent Care $45 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $125 |
| Emergency Room Visit | $125 If you are admitted to the hospital within 0 hours your cost share may be waived |
| Ambulance Transportation | $400 in-network|$400 out-of-network |
Health Care Services and Medical Supplies
Allina Health Aetna Medicare Essential (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|50% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Lab Services: In-Network|$0 for Hemoglobin A1C tests|$10 for other lab services||Out-of-Network|$35 Diagnostic Procedures: In-Network|$0 for certain Medicare-covered diagnostic tests and services including Retinal fundus, Spirometry, Peripheral arterial disease (PAD)||$35 for other diagnostic procedures and tests||Out-of-Network|50% Imaging: Xray: $15 in-network|$60 out-of-network|CT Scans: $150 in-network|Diagnostic Radiology other than CT Scans: $150 in-network|Diagnostic Radiology Mammogram: $0 in-network|50% out-of-network |
| Home Health Care | $0 in-network|50% out-of-network |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $345 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Psychiatric Hospital Services: Coinsurance for Psychiatric Hospital per Stay 50% |
| Mental Health Outpatient Care | In-Network|$45 for Mental Health: Group Sessions|$45 for Mental Health: Individual Sessions|$45 for Psychiatric Services: Group Sessions|$45 for Psychiatric Services: Individual Sessions||Out-of-Network|$60 for Mental Health Services- Group Sessions|$60 for Mental Health Services - Individual Sessions|$60 for Psychiatric Services: Group Sessions|$60 for Psychiatric Services: Individual Sessions |
| Outpatient Services / Surgery | Ambulatory Surgical Center: In-Network|$0 for preventive and diagnostic colonoscopy|$400 all other ambulatory surgical center services||Out-of-Network|50% |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $45 Copayment for Medicare-covered Group Sessions $45 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 $60 Copayment for Medicare Covered Group Sessions $60 |
| Over-the-counter (OTC) Items | $45 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 $45 Copayment for Routine Foot Care $45
Out-of-Network: Medicare Covered Podiatry Services: Copayment for Medicare Covered Podiatry Services $60 Non-Medicare Covered Podiatry Services: Copayment for Non-Medicare Covered Podiatry Services $60 |
| Skilled Nursing Facility Care | $10 per day, days 1-20 $214 per day, days 21-46 $0 per day, days 47-100 in-network|50% 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:|50% for oral exams|50% for cleanings|50% for fluoride treatments|50% for x-rays|50% for other diagnostic dental services|50% for other preventive dental services||Comprehensive dental services:|50% for restorative services|50% for endodontic services|50% for periodontic services|50% for removeable prosthodontics|50% for fixed prosthodontics|50% for oral and maxillofacial surgery|50% for adjunctive services||$600 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|$45 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:|50% for Medicare-covered eye exams|50% for non-Medicare covered eye exams|(Maximum one non-Medicare covered eye exam every year in or out-of-network)||Eyewear:|50% 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||$100 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:|$40 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:|50% for Medicare-covered hearing exams|50% 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|50% for all other preventive services covered under Original Medicare |
Prescription Drug Costs and Coverage
The Allina Health Aetna Medicare Essential (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $590 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $590 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $590 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $590 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
