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Aetna Medicare Dual Signature Select (PPO D-SNP) - H2293-003-000
$0.00
Monthly Premium
Aetna Medicare Dual Signature Select (PPO D-SNP) is a PPO D-SNP Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H2293-003-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Georgia Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about Georgia Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Enrollment may be limited to certain times of the year. See why you may be able to enroll.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $9,350.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | $0 in-network|$0 - $0 based on level of Medicaid eligibility out-of-network |
| Specialty doctor visit | In-Network|$0 - $15 based on level of Medicaid eligibility.||Out-of-Network|$0 - $15 based on level of Medicaid eligibility |
| Inpatient hospital care | $0 - $380 per day, days 1-7; $0 per day, days 8-90 based on level of Medicaid eligibility in-network.|$0 - $380 per day, days 1-7; $0 per day, days 8-90 based on level of Medicaid eligibility out-of-network |
| Urgent care | Urgent Care: Copayment for Urgent Care $0 or $15 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0 Maximum Plan Benefit of $250,000 |
| Emergency room visit | $0 - $110 based on level of Medicaid eligibility. If you are admitted to the hospital within 24 hours your cost share may be waived. |
| Ambulance transportation | $0 - $280 based on level of Medicaid eligibility in-network.|$0 - $280 based on level of Medicaid eligibility out-of-network |
Health Care Services and Medical Supplies
Aetna Medicare Dual Signature Select (PPO D-SNP) covers a range of additional benefits. Learn more about Aetna Medicare Dual Signature Select (PPO D-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $0 or $15 Copayment for Routine Care $0
|
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network|0%||Out-of-Network|0% for OneTouch/LifeScan diabetic supplies|$0 - 20% based on level of Medicaid eligibility for other covered diabetic supplies |
| Durable medical equipment (DME) | In-Network|$0 - 20% based on level of Medicaid eligibility.||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 - 40% based on level of Medicaid eligibility Diagnostic Procedures: In-Network|$0 for certain Medicare-covered diagnostic tests and services including Retinal fundus, Spirometry, Peripheral arterial disease (PAD)||$0 for services provided by your primary care physician in their office|$0 - $95 based on level of Medicaid eligibility for services performed by a provider other than your primary care physician||Out-of-Network|$0 - 20% based on level of Medicaid eligibility Imaging: Xray: $0 - $35 in-network|$0 - 40% based on level of Medicaid eligibility out-of-network|CT Scans: $0 - 20% in-network|Diagnostic Radiology other than CT Scans: $0 - 20% in-network|based on level of Medicaid eligibility |Diagnostic Radiology Mammogram: 0% in-network|$0 - 20% based on level of Medicaid eligibility out-of-network |
| Home health care | $0 in-network||$0 - $0 based on level of Medicaid eligibility out-of-network |
| Mental health inpatient care | 0 or $In-Network: Psychiatric Hospital Services: $678 per day for days 1 to 3 $0 per day for days 4 to 90 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | In-Network|$0 - $40 for Mental Health - Group Sessions|$0 - $40 for Mental Health - Individual Sessions|$0 - $40 for Psychiatric Services - Group Sessions|$0 - $40 for Psychiatric Services - Individual Sessions||based on level of Medicaid eligibility||Out-of-Network|$0 - 40% for Mental Health Services- Group Sessions based on level of Medicaid eligibility|$0 - 40% for Mental Health Services - Individual Sessions based on level of Medicaid eligibility|$0 - 40% for Psychiatric Services - Group Sessions based on level of Medicaid eligibility|$0 - 40% for Psychiatric Services - Individual Sessions based on level of Medicaid eligibility |
| Outpatient services/surgery | Ambulatory Surgical Center: In-Network|$0 for preventive and diagnostic colonoscopy|$0 - $280 for all other ambulatory surgical center services based on level of Medicaid eligibility||Out-of-Network|$0 - 20% based on level of Medicaid eligibility |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare-covered Individual Sessions 0% or 20% Coinsurance for Medicare-covered Group Sessions 0% or 20% Prior Authorization Required for Outpatient Substance Abuse Services |
| Over-the-counter items | By qualifying for enrollment in this plan, members receive coverage for approved over-the-counter (OTC) products under the Extra Supports Wallet on the Extra Benefits Card. |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $0 or $15 Copayment for Routine Foot Care $0
|
| Skilled Nursing Facility (SNF) care | $0 - $0 per day, days 1-20; $214 per day, days 21-100 based on level of Medicaid eligibility in-network|$0 - $0 per day, days 1-20; $214 per day, days 21-100 based on level of Medicaid eligibility out-of-network |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan 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:|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||$1,500 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, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | In-Network||Eye Exams:|$0 for Diabetic eye exams|$0-$15 based on level of Medicaid eligibility 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:|$0-$15 based on level of Medicaid eligibility for 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%-40% based on level of Medicaid eligibility 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||$305 benefit amount (allowance) every year for non-Medicare covered prescription eyewear. |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network||Hearing Exams:|$0-$15 based on level of 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)|$0 for fitting/evaluation for hearing aids|(Maximum one hearing aid fitting/evaluation every year)||Hearing Aids:|$0 for hearing aids|$1,250 benefit amount (allowance) per ear, every year for hearing aids|(Maximum two hearing aids every year)||Out-of-Network:||Hearing Exams:|$0-$15 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
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | In-Network|$0 copay 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 |
When reviewing Georgia Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Georgia that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Georgia Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.