Luckily, his health plan has some fixed costs and only requires $30 copays for visits to his regular doctor and $50 copays to see specialists like an orthopedist. (He also once paid a $150 copay the night he landed in the emergency room when his knee was so swollen he couldn’t bend it.). Your copay may be lower for PCP visits. A copay is a fixed dollar amount you pay at the time of a visit. Any network provider Visit any network doctor or specialist without a referral. Network doctors contract with Aetna to offer rates that are often lower than their regular fees. A specialist is a doctor who focuses only.
Aetna Medicare Prime (HMO-POS) H2663-015 is a 2020 Medicare Advantage Plan or Medicare Part-C plan by Aetna Medicare available to residents in Missouri. This plan includes additional Medicare prescription drug (Part-D) coverage. The Aetna Medicare Prime (HMO-POS) has a monthly premium of $- and has an in-network Maximum Out-of-Pocket limit of $2,600 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $2,600 out of pocket. This can be a extremely nice safety net.
Aetna Medicare Prime (HMO-POS) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered by the plan.
Aetna Medicare works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Aetna Medicare Prime (HMO-POS) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Aetna Medicare and not Original Medicare. With Medicare Advantage Plans you are always covered for urgently needed and emergency care. Plus you receive all of the benefits of Original Medicare from Aetna Medicare except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.
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2020 Aetna Medicare Medicare Advantage Plan Details
| Name: |
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| ID: | H2663-015 |
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| Provider: | Aetna Medicare |
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| Year: | 2020 |
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| Type: | Local HMO |
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| Monthly Premium C+D: | $- |
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| Part C Premium: | $0.00 |
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| MOOP: | $2,600 |
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| Part D (Drug) Premium: | $0.00 |
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| Part D Supplemental Premium | $0.00 |
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| Total Part D Premium: | $0.00 |
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| Drug Deductible: | $0.00 |
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| Tiers with No Deductible: | 0 |
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| Gap Coverage: | Yes |
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| Benchmark: | not below the regional benchmark |
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| Type of Medicare Health: | Enhanced Alternative |
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| Drug Benefit Type: | Enhanced |
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Part-C Premium
Aetna Medicare plan charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.
Part-D Deductible and Premium
Aetna Medicare Prime (HMO-POS) has a monthly drug premium of $0.00 and a $0.00 drug deductible. This Aetna Medicare plan offers a $0.00 Part D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Aetna Medicare above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $0.00. The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.
Premium Assistance
Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Aetna Medicare Prime (HMO-POS) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $0.00 for 75% low income subsidy $0.00 for 50% and $0.00 for 25%.
| Full LIS Premium: | $0.00 |
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| 75% LIS Premium: | $0.00 |
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| 50% LIS Premium: | $0.00 |
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| 25% LIS Premium: | $0.00 |
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Gap Coverage
In 2020 once you and your plan provider have spent $4020 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA 'donut hole') You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Aetna Medicare plan does offer additional coverage through the gap.
Aetna Medicare Drug Coverage and Formulary
A formulary is divided into tiers or levels of coverage based on the type or usage of your medication or benefit categories, according to drug costs. Each tier will have a defined out-of-pocket cost that you must pay before receiving the drug. You can see complete 2020 Aetna Medicare Prime (HMO-POS) H2663-015 Formulary here.
See the 2020 Aetna Medicare Formulary
2019 Plan Services
(*2020 Plan services will be added when available)
Health plan deductible
Emergency care/Urgent care
| Emergency | $90 per visit (always covered) |
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| Urgent care | $65 per visit (always covered) |
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Does Aetna Require A Referral To See A Specialist
Diagnostic procedures/lab services/imaging
| Diagnostic tests and procedures | Out-of-Network | 30% |
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| Diagnostic tests and procedures | In-Network | $280 or 20% |
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| Lab services | Out-of-Network | 30% |
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| Lab services | In-Network | $0 |
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| Diagnostic radiology services (e.g., MRI) | Out-of-Network | 30% |
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| Diagnostic radiology services (e.g., MRI) | In-Network | $40-140 |
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| Outpatient x-rays | Out-of-Network | 30% |
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| Outpatient x-rays | In-Network | $10 |
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Hearing
| Hearing exam | Out-of-Network | 30% |
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| Hearing exam | In-Network | $40 |
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| Fitting/evaluation | In-Network | $0 copay |
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| Hearing aids | In-Network | $0 copay |
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Preventive dental
| Oral exam | In-Network | $0 copay |
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| Cleaning | In-Network | $0 copay |
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| Fluoride treatment | Not covered |
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| Dental x-ray(s) | In-Network | $0 copay |
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Comprehensive dental
| Non-routine services | Not covered |
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| Diagnostic services | Not covered |
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| Restorative services | In-Network | 50% |
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| Endodontics | In-Network | 50% |
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| Periodontics | In-Network | 50% |
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| Extractions | In-Network | 50% |
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| Prosthodontics, other oral/maxillofacial surgery, other services | In-Network | 50% |
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Vision
| Routine eye exam | Out-of-Network | 30% |
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| Routine eye exam | In-Network | $0 copay |
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| Other | Not covered |
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| Contact lenses | In-Network | $0 copay |
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| Eyeglasses (frames and lenses) | In-Network | $0 copay |
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| Eyeglass frames | In-Network | $0 copay |
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| Eyeglass lenses | In-Network | $0 copay |
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| Upgrades | In-Network | $0 copay |
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Mental health services
| Inpatient hospital - psychiatric | Out-of-Network | 30% per stay |
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| Inpatient hospital - psychiatric | In-Network | $250 per day for days 1 through 5
$0 per day for days 6 through 90 |
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| Outpatient group therapy visit with a psychiatrist | Out-of-Network | 30% |
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| Outpatient group therapy visit with a psychiatrist | In-Network | $40 |
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| Outpatient individual therapy visit with a psychiatrist | Out-of-Network | 30% |
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| Outpatient individual therapy visit with a psychiatrist | In-Network | $40 |
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| Outpatient group therapy visit | Out-of-Network | 30% |
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| Outpatient group therapy visit | In-Network | $40 |
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| Outpatient individual therapy visit | Out-of-Network | 30% |
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| Outpatient individual therapy visit | In-Network | $40 |
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Skilled Nursing Facility
| Out-of-Network | 30% per stay |
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| In-Network | $20 per day for days 1 through 20
$167 per day for days 21 through 100 |
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Rehabilitation services
| Occupational therapy visit | Out-of-Network | 30% |
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| Occupational therapy visit | In-Network | $40 |
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| Physical therapy and speech and language therapy visit | Out-of-Network | 30% |
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| Physical therapy and speech and language therapy visit | In-Network | $40 |
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Ground ambulance
| Out-of-Network | $285 |
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| In-Network | $285 |
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Other health plan deductibles?
Transportation
Foot care (podiatry services)
| Foot exams and treatment | Out-of-Network | 30% |
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| Foot exams and treatment | In-Network | $40 |
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| Routine foot care | Out-of-Network | 30% |
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| Routine foot care | In-Network | $40 |
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Medical equipment/supplies
| Durable medical equipment (e.g., wheelchairs, oxygen) | Out-of-Network | 30% per item |
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| Durable medical equipment (e.g., wheelchairs, oxygen) | In-Network | 20% per item |
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| Prosthetics (e.g., braces, artificial limbs) | Out-of-Network | 30% per item |
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| Prosthetics (e.g., braces, artificial limbs) | In-Network | 20% per item |
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| Diabetes supplies | Out-of-Network | 0-20% per item |
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| Diabetes supplies | In-Network | 0-20% per item |
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Wellness programs (e.g., fitness, nursing hotline)
Medicare Part B drugs
| Chemotherapy | Out-of-Network | 30% |
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| Chemotherapy | In-Network | 20% |
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| Other Part B drugs | Out-of-Network | 30% |
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| Other Part B drugs | In-Network | 20% |
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Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
Optional supplemental benefits
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
Inpatient hospital coverage
| Out-of-Network | 30% per stay |
|---|
| In-Network | $250 per day for days 1 through 5
$0 per day for days 6 through 90 |
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Outpatient hospital coverage
| Out-of-Network | 30% per visit |
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| In-Network | $280 per visit |
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Doctor visits
| Primary | Out-of-Network | 30% per visit |
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| Primary | In-Network | $0 copay |
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| Specialist | Out-of-Network | 30% per visit |
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| Specialist | In-Network | $40 per visit |
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Preventive care
| Out-of-Network | 0-30% |
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| In-Network | $0 copay |
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Ratings for Aetna Medicare Prime (HMO-POS) H2663
| 2019 Overall Rating |
|---|
| Part C Summary Rating |
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| Part D Summary Rating |
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| Staying Healthy: Screenings, Tests, Vaccines |
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| Managing Chronic (Long Term) Conditions |
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| Member Experience with Health Plan |
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| Complaints and Changes in Plans Performance |
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| Health Plan Customer Service |
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| Drug Plan Customer Service |
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| Complaints and Changes in the Drug Plan |
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| Member Experience with the Drug Plan |
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| Drug Safety and Accuracy of Drug Pricing |
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Staying Healthy, Screening, Testing, & Vaccines
| Total Preventative Rating |
|---|
| Breast Cancer Screening |
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| Colorectal Cancer Screening |
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| Annual Flu Vaccine |
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| Improving Physical |
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| Improving Mental Health |
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| Monitoring Physical Activity |
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| Adult BMI Assessment |
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Managing Chronic And Long Term Care for Older Adults
| Total Rating |
|---|
| SNP Care Management |
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| Medication Review |
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| Functional Status Assessment |
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| Pain Screening |
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| Osteoporosis Management |
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| Diabetes Care - Eye Exam |
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| Diabetes Care - Kidney Disease |
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| Diabetes Care - Blood Sugar |
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| Rheumatoid Arthritis |
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| Reducing Risk of Falling |
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| Improving Bladder Control |
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| Medication Reconciliation |
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| Plan All-Cause Readmissions |
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| Statin Therapy |
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Member Experience with Health Plan
| Total Experience Rating |
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| Getting Needed Care |
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| Timely Care and Appointments |
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| Customer Service |
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| Health Care Quality |
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| Rating of Health Plan |
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| Care Coordination |
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Member Complaints and Changes in Aetna Medicare Prime (HMO-POS) Plans Performance
| Total Rating |
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| Complaints about Health Plan |
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| Members Leaving the Plan |
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| Health Plan Quality Improvement |
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Health Plan Customer Service Rating for Aetna Medicare Prime (HMO-POS)
| Total Customer Service Rating |
|---|
| Timely Decisions About Appeals |
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| Reviewing Appeals Decisions |
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| Call Center, TTY, Foreign Language |
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Aetna Medicare Prime (HMO-POS) Drug Plan Customer Service ratings
| Total Rating |
|---|
| Call Center, TTY, Foreign Language |
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| Appeals Auto |
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| Appeals Upheld |
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Ratings For Member Complaints and Changes in the Drug Plans Performance
| Total Rating |
|---|
| Complaints about the Drug Plan |
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| Members Choosing to Leave the Plan |
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| Drug Plan Quality Improvement |
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Member Experience with the Drug Plan
Aetna Default Copay
| Total Rating |
|---|
| Rating of Drug Plan |
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| Getting Needed Prescription Drugs |
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Drug Safety and Accuracy of Drug Pricing
| Total Rating |
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| MPF Price Accuracy |
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| Drug Adherence for Diabetes Medications |
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| Drug Adherence for Hypertension (RAS antagonists) |
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| Drug Adherence for Cholesterol (Statins) |
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| MTM Program Completion Rate for CMR |
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| Statin with Diabetes |
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Ready to Enroll?
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Mon-Sat 8am-11pm EST
Sun 9am-6pm EST
How To Pay Aetna Copay
Coverage Area for Aetna Medicare Prime (HMO-POS)
(Click county to compare all available Advantage plans)
| State: | Missouri
|
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| County: | Franklin, Jefferson, St. Charles, St. Louis, St. Louis City,
|
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Source: CMS.
Data as of September 4, 2019.
Star Rating as of October 10, 2019.
Plan Services are 2019 information as reference. 2020 information will be added when released.
Notes: Data are subject to change as contracts are finalized. For 2020, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit.Includes 2020 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.