Allina Health Aetna Medicare Grand (PPO)

Aetna Inc.
Allina Health Aetna Medicare Grand (PPO) H3219-003 Plan Details
4 out of 5 stars

Allina Health Aetna Medicare Grand (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H3219-003

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.

$66.00
Monthly Premium

Allina Health Aetna Medicare Grand (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H3219-003

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 Inc.
Allina Health Aetna Medicare Grand (PPO) H3219-003 Plan Details
4 out of 5 stars

Allina Health Aetna Medicare Grand (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H3219-003

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.

$66.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $3300
Out-of-Network: N/A
Initial Coverage Limit $2000
Catastrophic Coverage Limit $2,000
Primary Care Doctor Visit
$0 in-network|$25 out-of-network
Specialty Doctor Visit
In-Network|$0 for services provided in a nursing home|$20 for services provided outside a nursing home||Out-of-Network|$40
Inpatient Hospital Care
$195 per stay in-network|25% per stay out-of-network
Urgent Care
Copayment for Urgent Care $20

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 Grand (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
  • Maximum 18 Routine Care every year
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|25%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
Lab Services: In-Network|$0 ||Out-of-Network|$0
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|$20
Imaging: Xray: $15 in-network|$20 out-of-network|CT Scans: $75 in-network|Diagnostic Radiology other than CT Scans: $75 in-network|Diagnostic Radiology Mammogram: $0 in-network|$150 out-of-network
Home Health Care
$0 in-network|25% out-of-network
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $195
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:

Psychiatric Hospital Services:
Coinsurance for Psychiatric Hospital per Stay 25%
Mental Health Outpatient Care
In-Network|$20 for Mental Health:
Group Sessions|$20 for Mental Health:
Individual Sessions|$20 for Psychiatric Services:
Group Sessions|$20 for Psychiatric Services:
Individual Sessions||Out-of-Network|$40 for Mental Health Services- Group Sessions|$40 for Mental Health Services - Individual Sessions|$40 for Psychiatric Services:
Group Sessions|$40 for Psychiatric Services:
Individual Sessions
Outpatient Services / Surgery
Ambulatory Surgical Center: In-Network|$0 for preventive and diagnostic colonoscopy|$175 all other ambulatory surgical center services||Out-of-Network|$350
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $20
Copayment for Medicare-covered Group Sessions $20
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 $40
Copayment for Medicare Covered Group Sessions $40
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 $20
Copayment for Routine Foot Care $20
  • Maximum 12 visits every year
Out-of-Network:

Medicare Covered Podiatry Services:
Copayment for Medicare Covered Podiatry Services $40

Non-Medicare Covered Podiatry Services:
Copayment for Non-Medicare Covered Podiatry Services $40
Skilled Nursing Facility Care
$0 per day, days 1-20
$214 per day, days 21-36
$0 per day, days 37-100 in-network|25% 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||$1,800 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|$20 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:|$40 for Medicare-covered eye exams|$20 for non-Medicare covered eye exams|(Maximum one non-Medicare covered eye exam every year in or out-of-network)||Eyewear:|25% 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||$200 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:|$20 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|$1,000 benefit amount (allowance) per ear, every year for hearing aids|(Maximum two hearing aids every year)||Out-of-Network:||Hearing Exams:|$40 for Medicare-covered hearing exams|$40 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|25% for all other preventive services covered under Original Medicare