2019 Medicare Advantage Plan Services for
Aetna Medicare Basics Plan (PPO)
Aetna Medicare Basics Plan (PPO) H5521-179 is a 2019 Medicare Advantage or Medicare Part-C plan by Aetna Medicare available to residents in Georgia. This plan does not provide additional Medicare prescription drug (Part-D) coverage. The Aetna Medicare Basics Plan (PPO) has a monthly premium of $- and has an in-network Maximum Out-of-Pocket limit of $5,900 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $5,900 out of pocket. This can be a extremely nice safety net.
Aetna Medicare Basics Plan (PPO) is a Local PPO *. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.
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 Basics Plan (PPO) 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.
2019 Aetna Medicare Medicare Advantage Plan Details
| Name: | Aetna Medicare Basics Plan (PPO) |
|---|---|
| ID: | H5521-179 |
| Provider: | Aetna Medicare |
| Year: | 2019 |
| Type: | Local PPO * |
| Monthly Premium C+D: | $- |
| Part C Premium: | |
| MOOP: | $5,900 |
Plan Services
Health plan deductible
| $0 |
|---|
Emergency care/Urgent care
| Emergency | $90 per visit (always covered) | |
|---|---|---|
| Urgent care | $5-20 per visit (always covered) |
Diagnostic procedures/lab services/imaging
| Diagnostic tests and procedures | Out-of-Network | 35% |
|---|---|---|
| Diagnostic tests and procedures | In-Network | $5-95 |
| Lab services | Out-of-Network | 35% |
| Lab services | In-Network | $5-15 |
| Diagnostic radiology services (e.g., MRI) | Out-of-Network | 35% |
| Diagnostic radiology services (e.g., MRI) | In-Network | $5-150 |
| Outpatient x-rays | Out-of-Network | 35% |
| Outpatient x-rays | In-Network | $5-25 |
Hearing
| Hearing exam | Out-of-Network | $30 |
|---|---|---|
| Hearing exam | In-Network | $20 |
| Fitting/evaluation | Out-of-Network | $30 |
| Fitting/evaluation | In-Network | $20 |
| Hearing aids - inner ear | Not covered | |
| Hearing aids - outer ear | Not covered | |
| Hearing aids - over the ear | Not covered |
Preventive dental
| Oral exam | Out-of-Network | $0 copay |
|---|---|---|
| Oral exam | In-Network | $0 copay |
| Cleaning | Out-of-Network | $0 copay |
| Cleaning | In-Network | $0 copay |
| Fluoride treatment | Out-of-Network | $0 copay |
| Fluoride treatment | In-Network | $0 copay |
| Dental x-ray(s) | Out-of-Network | $0 copay |
| Dental x-ray(s) | In-Network | $0 copay |
Comprehensive dental
| Non-routine services | Out-of-Network | $0 copay |
|---|---|---|
| Non-routine services | In-Network | $0 copay |
| Diagnostic services | Out-of-Network | $0 copay |
| Diagnostic services | In-Network | $0 copay |
| Restorative services | Out-of-Network | $0 copay |
| Restorative services | In-Network | $0 copay |
| Endodontics | Out-of-Network | $0 copay |
| Endodontics | In-Network | $0 copay |
| Periodontics | Out-of-Network | $0 copay |
| Periodontics | In-Network | $0 copay |
| Extractions | Out-of-Network | $0 copay |
| Extractions | In-Network | $0 copay |
| Prosthodontics, other oral/maxillofacial surgery, other services | Out-of-Network | $0 copay |
| Prosthodontics, other oral/maxillofacial surgery, other services | In-Network | $0 copay |
Vision
| Routine eye exam | Out-of-Network | $0 copay |
|---|---|---|
| Routine eye exam | In-Network | $0 copay |
| Other | Not covered | |
| Contact lenses | Out-of-Network | $0 copay |
| Contact lenses | In-Network | $0 copay |
| Eyeglasses (frames and lenses) | Out-of-Network | $0 copay |
| Eyeglasses (frames and lenses) | In-Network | $0 copay |
| Eyeglass frames | Out-of-Network | $0 copay |
| Eyeglass frames | In-Network | $0 copay |
| Eyeglass lenses | Out-of-Network | $0 copay |
| Eyeglass lenses | In-Network | $0 copay |
| Upgrades | Out-of-Network | $0 copay |
| Upgrades | In-Network | $0 copay |
Mental health services
| Inpatient hospital - psychiatric | Out-of-Network | 35% per stay |
|---|---|---|
| Inpatient hospital - psychiatric | In-Network | $295 per day for days 1 through 5 $0 per day for days 6 through 90 |
| Outpatient group therapy visit with a psychiatrist | Out-of-Network | $50 |
| Outpatient group therapy visit with a psychiatrist | In-Network | $35 |
| Outpatient individual therapy visit with a psychiatrist | Out-of-Network | $50 |
| Outpatient individual therapy visit with a psychiatrist | In-Network | $35 |
| Outpatient group therapy visit | Out-of-Network | $50 |
| Outpatient group therapy visit | In-Network | $35 |
| Outpatient individual therapy visit | Out-of-Network | $50 |
| Outpatient individual therapy visit | In-Network | $35 |
Skilled Nursing Facility
| Out-of-Network | 35% per stay | |
|---|---|---|
| In-Network | $0 per day for days 1 through 20 $160 per day for days 21 through 100 |
Rehabilitation services
| Occupational therapy visit | Out-of-Network | $50 |
|---|---|---|
| Occupational therapy visit | In-Network | $20 |
| Physical therapy and speech and language therapy visit | Out-of-Network | $50 |
| Physical therapy and speech and language therapy visit | In-Network | $20 |
Ground ambulance
| Out-of-Network | $250 | |
|---|---|---|
| In-Network | $250 |
Other health plan deductibles?
| In-Network | No |
|---|
Transportation
| Not covered |
|---|
Foot care (podiatry services)
| Foot exams and treatment | Out-of-Network | $30 |
|---|---|---|
| Foot exams and treatment | In-Network | $20 |
| Routine foot care | Not covered |
Medical equipment/supplies
| Durable medical equipment (e.g., wheelchairs, oxygen) | Out-of-Network | 25% per item |
|---|---|---|
| Durable medical equipment (e.g., wheelchairs, oxygen) | In-Network | 15% per item |
| Prosthetics (e.g., braces, artificial limbs) | Out-of-Network | 25% per item |
| Prosthetics (e.g., braces, artificial limbs) | In-Network | 15% per item |
| Diabetes supplies | Out-of-Network | 0-20% per item |
| Diabetes supplies | In-Network | 0-20% per item |
Wellness programs (e.g., fitness, nursing hotline)
| Covered |
|---|
Medicare Part B drugs
| Chemotherapy | Out-of-Network | 35% |
|---|---|---|
| Chemotherapy | In-Network | 20% |
| Other Part B drugs | Out-of-Network | 35% |
| Other Part B drugs | In-Network | 20% |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $10,000 In and Out-of-network $5,900 In-network |
|---|
Optional supplemental benefits
| No |
|---|
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network | No |
|---|
Inpatient hospital coverage
| Out-of-Network | 35% per stay | |
|---|---|---|
| In-Network | $250 per day for days 1 through 7 $0 per day for days 8 through 90 |
Outpatient hospital coverage
| Out-of-Network | 35% per visit | |
|---|---|---|
| In-Network | $20-150 per visit |
Doctor visits
| Primary | Out-of-Network | $20 per visit |
|---|---|---|
| Primary | In-Network | $5 per visit |
| Specialist | Out-of-Network | $30 per visit |
| Specialist | In-Network | $20 per visit |
Preventive care
| Out-of-Network | $0 copay | |
|---|---|---|
| In-Network | $0 copay |
Ratings for Aetna Medicare Basics Plan (PPO) H5521
| 2018 Overall Rating | ||
|---|---|---|
| Part C Summary Rating | ||
| Part D Summary Rating | ||
| Staying Healthy: Screenings, Tests, Vaccines | ||
| Managing Chronic (Long Term) Conditions | ||
| Member Experience with Health Plan | ||
| Complaints and Changes in Plans Performance | ||
| Health Plan Customer Service | ||
| Drug Plan Customer Service | ||
| Complaints and Changes in the Drug Plan | ||
| Member Experience with the Drug Plan | ||
| Drug Safety and Accuracy of Drug Pricing |
Staying Healthy, Screening, Testing, & Vaccines
| Total Preventative Rating | ||
|---|---|---|
| Breast Cancer Screening | ||
| Colorectal Cancer Screening | ||
| Annual Flu Vaccine | ||
| Improving Physical | ||
| Improving Mental Health | ||
| Monitoring Physical Activity | ||
| Adult BMI Assessment |
Managing Chronic And Long Term Care for Older Adults
| Total Rating | ||
|---|---|---|
| SNP Care Management | ||
| Medication Review | ||
| Functional Status Assessment | ||
| Pain Screening | ||
| Osteoporosis Management | ||
| Diabetes Care - Eye Exam | ||
| Diabetes Care - Kidney Disease | ||
| Diabetes Care - Blood Sugar | ||
| Controlling Blood Pressure | ||
| Rheumatoid Arthritis | ||
| Reducing Risk of Falling | ||
| Improving Bladder Control | ||
| Medication Reconciliation | ||
| Plan All-Cause Readmissions | ||
| Statin Therapy |
Member Experience with Health Plan
| Total Experience Rating | ||
|---|---|---|
| Getting Needed Care | ||
| Timely Care and Appointments | ||
| Customer Service | ||
| Health Care Quality | ||
| Rating of Health Plan | ||
| Care Coordination |
Member Complaints and Changes in Aetna Medicare Basics Plan (PPO) Plans Performance
| Total Rating | ||
|---|---|---|
| Complaints about Health Plan | ||
| Members Leaving the Plan | ||
| Health Plan Quality Improvement |
Health Plan Customer Service Rating for Aetna Medicare Basics Plan (PPO)
| Total Customer Service Rating | ||
|---|---|---|
| Timely Decisions About Appeals | ||
| Reviewing Appeals Decisions | ||
| Call Center, TTY, Foreign Language |
Aetna Medicare Basics Plan (PPO) Drug Plan Customer Service ratings
| Total Rating | ||
|---|---|---|
| Call Center, TTY, Foreign Language | ||
| Appeals Auto | ||
| Appeals Upheld |
Ratings For Member Complaints and Changes in the Drug Plans Performance
| Total Rating | ||
|---|---|---|
| Complaints about the Drug Plan | ||
| Members Choosing to Leave the Plan | ||
| Drug Plan Quality Improvement |
Member Experience with the Drug Plan
| Total Rating | ||
|---|---|---|
| Rating of Drug Plan | ||
| Getting Needed Prescription Drugs |
Drug Safety and Accuracy of Drug Pricing
| Total Rating | ||
|---|---|---|
| MPF Price Accuracy | ||
| Drug Adherence for Diabetes Medications | ||
| Drug Adherence for Hypertension (RAS antagonists) | ||
| Drug Adherence for Cholesterol (Statins) | ||
| MTM Program Completion Rate for CMR | ||
| Statin with Diabetes |
Coverage Area for Aetna Medicare Basics Plan (PPO)
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Source: CMS.
Data as of September 2, 2018.
Star Rating as of October 10, 2018.
For More Information on Ratings Please See the CMS Tech Notes.
Notes: Data are subject to change as contracts are finalized. For 2019, 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 2019 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.
