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Aetna Medicare Full Dual (PPO D-SNP) H5521-758 - H5521-758-000
$0.00
Monthly Premium
Aetna Medicare Full Dual (PPO D-SNP) H5521-758 is a PPO D-SNP Medicare Advantage (Medicare Part C) plan offered by Aetna®
Plan ID: H5521-758-000
** Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
If you have Medicare in South Dakota, you may want to review your coverage options. Medicare Advantage plans cover services that aren’t covered by Original Medicare (Part A and Part B).
Aetna Medicare Advantage plans may cover prescription drugs, and offer other benefits that Original Medicare doesn’t cover.
Aetna Medicare Full Dual (PPO D-SNP) H5521-758 basic costs and coverage
Learn more about the costs, benefits and coverage of Aetna Medicare Full Dual (PPO D-SNP) H5521-758 below:
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $700.00 |
| Out-of-pocket maximum | $9,850.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care provider visit | In-Network $0 Out-of-Network $0 - 30% based on level of Medicaid eligibility |
| Specialty doctor visit | In-Network $0 Out-of-Network $0 - 30% based on level of Medicaid eligibility |
| Inpatient hospital care | In-Network $0 Out-of-Network $0 - $2130 per stay based on level of Medicaid eligibility |
| Urgent care | Urgent Care: Copayment for Urgent Care $40 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0 Maximum Plan Benefit of $250,000 |
| Emergency room visit | $0 - $115 based on level of Medicaid eligibility. Cost share applies even if visit requires an admission to the hospital. |
| Ambulance transportation | In-Network $0 Out-of-Network $0 - 20% based on level of Medicaid eligibility |
Additional health services and supplies coverage
Aetna Medicare Full Dual (PPO D-SNP) H5521-758 covers additional health services and medical supplies. Learn more below:
| Coverage | Details |
|---|---|
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network 0% for blood glucose monitors (BGM) and continuous glucose monitors (CGM) Out-of-Network 0% for Accu-Chek/Roche and TRUE/Trividia blood glucose meters (BGM) and medical diabetic supplies $0 - 20% based on level of Medicaid eligibility for blood glucose meters (BGM) and supplies manufactured by providers other than Accu-Chek/Roche and TRUE/Trividia with an approved prior authorization $0 - 20% based on level of Medicaid eligibility for continuous glucose monitors (CGM) |
| Durable medical equipment (DME) | In-Network $0 Out-of-Network $0 - 20% based on level of Medicaid eligibility |
| Diagnostic tests, lab and radiology services, and X-rays | Lab Services: In-Network $0 Out-of-Network $0 - 30% based on level of Medicaid eligibility Diagnostic Procedures: In-Network $0 Out-of-Network $0 - 30% based on level of Medicaid eligibility Imaging: In-Network Xray: $0 CT Scans: $0 Diagnostic Radiology other than CT Scans: $0 Diagnostic Radiology Mammogram: $0 Out-of-Network $0 - 30% based on level of Medicaid eligibility |
| Home health care | In-Network $0 Out-of-Network $0 - 0% based on level of Medicaid eligibility |
| Mental health inpatient care | Out-of-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital per Stay $0 or $2080 |
| Mental health outpatient care | In-Network $0 for Mental Health - Group Sessions $0 for Mental Health - Individual Sessions $0 for Psychiatric Services - Group Sessions $0 for Psychiatric Services - Individual Sessions Out-of-Network $0 - 30% for Mental Health Services- Group Sessions based on level of Medicaid eligibility $0 - 30% for Mental Health Services - Individual Sessions based on level of Medicaid eligibility $0 - 30% for Psychiatric Services - Group Sessions based on level of Medicaid eligibility $0 - 30% for Psychiatric Services - Individual Sessions based on level of Medicaid eligibility |
| Outpatient services/surgery | Ambulatory Surgical Center: In-Network $0 Out-of-Network $0 - 30% based on level of Medicaid eligibility |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $0 Copayment for Medicare-covered Group Sessions $0 Prior Authorization Required for Outpatient Substance Abuse Services |
| Over-the-counter items | Over-the-Counter (OTC) Wallet with a $150 monthly benefit amount (allowance) on the Extra Benefits Card to help pay for approved OTC health and wellness products like first aid supplies, cold and allergy medicine, pain relievers, and more. Approved products can be purchased in-store at participating locations including CVS retail locations (excluding locations inside other stores), using the app, online or by phone through CVS Flex Benefits. Qualifying members may be eligible for additional spending categories. See EOC for more information. |
| Podiatry services | Out-of-Network: Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 0% or 30% |
| Skilled Nursing Facility (SNF) care | In-Network $0 Out-of-Network $0 - $0 per day, days 1-20; $221 per day, days 21-100 based on level of Medicaid eligibility |
Dental benefit
Aetna Medicare Full Dual (PPO D-SNP) H5521-758 offers the following dental benefit and coverage. There may be provider network restrictions. You can find more information about network restrictions in the plan’s Evidence of Coverage.
| Coverage | Details |
|---|---|
| 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: $0 for oral exams $0 for cleanings $0 for fluoride treatments $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 $1,900 benefit amount (allowance) every year in and out-of-network for covered preventive and comprehensive dental services combined. Frequencies and medical necessity requirements vary by covered dental service. ADA recognized dental services are covered up to the benefit amount excluding implants and implant related services, orthodontics, cosmetic services, those considered medical in nature, and administrative charges. See EOC for a full list of exclusions. |
Vision benefit
Aetna Medicare Full Dual (PPO D-SNP) H5521-758 offers the following vision benefit. There may be provider network restrictions. You can find more information about network restrictions in the plan's Evidence of Coverage.
| Coverage | Details |
|---|---|
| Vision care | In-Network Eye Exams: 0% for Medicare-covered eye exams $0 for non-Medicare covered routine eye exam with an EyeMed network provider Eyewear: 0% for Medicare-covered prescription eyewear $200 annual benefit amount (allowance) for non-Medicare covered prescription eyewear through an EyeMed network provider. $0 for Contacts $0 for Eyeglasses $0 for Eyeglass Frames $0 for Eyeglass Lenses $0 for Upgrades Out-of-Network Eye Exams: 0%-30% based on level of Medicaid eligibility for Medicare-covered eye exams $0 for non-Medicare covered routine eye exam (out of network covered up to $50) Eyewear: 0%-30% based on level of Medicaid eligibility for Medicare-covered prescription eyewear $200 annual benefit amount (allowance) for non-Medicare covered prescription eyewear $0 for Contacts $0 for Eyeglass Frames $0 for Eyeglass Lenses $0 for Eyeglass Lenses and Frames $0 for Upgrades Maximum one non-Medicare covered routine eye exam every calendar year in or out-of-network. Maximum one annual benefit amount for non-Medicare covered prescription eyewear in or out-of-network. |
Hearing benefit
Aetna Medicare Full Dual (PPO D-SNP) H5521-758 offers the following hearing benefit and coverage. There may be provider network restrictions. You can find more information about network restrictions in the plan’s Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network Hearing Exams: 0% 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: 0%-30% based on level of Medicaid eligibility 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 Hearing Aids: You must purchase hearing aids through NationsHearing |
Preventive services and health/wellness education programs
Aetna Medicare Full Dual (PPO D-SNP) H5521-758 offers the following preventive services, benefits and wellness programs. There may be provider network restrictions. You can find more information about network restrictions in the plan’s Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | In-Network $0 for all preventive services covered under Original Medicare Out-of-Network $0 based on level of Medicaid eligibility for all preventive services covered under Original Medicare |
We can help you find out if your doctors are in a plan’s network when reviewing Aetna Medicare Advantage plans in South Dakota. We can also help you look for plans that cover your prescription drugs.
There may be other Aetna Medicare Advantage plans available in South Dakota. Call 1-800-891-6309 (TTY: 711), 24/7 to speak with a licensed TZ insurance agent* who can help you compare plans where you live.
Plan documents
Learn more about Aetna Medicare Full Dual (PPO D-SNP) H5521-758 by reviewing the following documents:
| Links to plan documents |
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