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Aetna Medicare Longevity (HMO I-SNP) - H3959-066-000
$48.40
Monthly Premium
Aetna Medicare Longevity (HMO I-SNP) is a HMO I-SNP Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H3959-066-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$48.40
Monthly Premium
Pennsylvania 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 Pennsylvania Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $48.40 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $590.00 |
| 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 |
| Specialty doctor visit | In-Network|0% for services provided in a nursing home|20% for services provided outside a nursing home |
| Inpatient hospital care | $1,632 deductible plus $0 per day, days 1-60; $408 per day, days 61-90 per benefit period |
| Urgent care | Urgent Care: Copayment for Urgent Care $45 |
| Emergency room visit | $110 If you are admitted to the hospital within 24 hours your cost share may be waived |
| Ambulance transportation | 20% |
Health Care Services and Medical Supplies
Aetna Medicare Longevity (HMO I-SNP) covers a range of additional benefits. Learn more about Aetna Medicare Longevity (HMO I-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: Coinsurance for Medicare-covered Chiropractic Services 20% Prior Authorization Required for Chiropractic Services |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network|20% |
| Durable medical equipment (DME) | In-Network|20% |
| Diagnostic tests, lab and radiology services, and X-rays | Lab Services: In-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 Imaging: Xray: 20% in-network|CT Scans: 20% in-network|Diagnostic Radiology other than CT Scans: 20% in-network|Diagnostic Radiology Mammogram: 0% in-network |
| Home health care | $0 |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $0 Prior Authorization Required for Psychiatric Hospital Services |
| 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 |
| Outpatient services/surgery | Ambulatory Surgical Center: In-Network|0% for preventive and diagnostic colonoscopy|20% all other ambulatory surgical center services |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare-covered Individual Sessions 20% Coinsurance for Medicare-covered Group Sessions 20% Prior Authorization Required for Outpatient Substance Abuse Services |
| Over-the-counter items | $390 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: Podiatry Services: Coinsurance for Medicare-Covered Podiatry Services 20% Copayment for Routine Foot Care $0
|
| Skilled Nursing Facility (SNF) care | $0 per stay in-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|$3,500 benefit amount (allowance) every year for covered preventive and comprehensive dental services. Frequencies and medical necessity requirements vary by covered dental service.||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 non-Medicare covered eye exams|(Maximum one non-Medicare covered eye exam every year)||Eyewear:|$0 for Contacts|$0 for Eyeglasses|$0 for Eyeglass Frames|$0 for Eyeglass Lenses|$0 for Upgrades||$250 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:|20% for Medicare-covered hearing exams|$0 for non-Medicare covered hearing exams|(Maximum one non-Medicare covered hearing exam every year)|$0 for fitting/evaluation for hearing aids|(Maximum one hearing aid fitting/evaluation every year)||Hearing Aids:|$0 for hearing aids|$750 benefit amount (allowance) per ear, every year for hearing aids|(Maximum two hearing aids every year) |
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 |
When reviewing Pennsylvania 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 Pennsylvania 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 |
Pennsylvania Counties Served
- Adams
- Allegheny
- Armstrong
- Beaver
- Bedford
- Berks
- Blair
- Bradford
- Bucks
- Butler
- Cambria
- Cameron
- Carbon
- Centre
- Chester
- Clarion
- Clearfield
- Clinton
- Columbia
- Crawford
- Cumberland
- Dauphin
- Delaware
- Elk
- Erie
- Fayette
- Forest
- Franklin
- Fulton
- Greene
- Huntingdon
- Indiana
- Jefferson
- Juniata
- Lackawanna
- Lancaster
- Lawrence
- Lebanon
- Lehigh
- Luzerne
- Lycoming
- Mckean
- Mercer
- Mifflin
- Monroe
- Montgomery
- Montour
- Northampton
- Northumberland
- Perry
- Philadelphia
- Pike
- Potter
- Schuylkill
- Snyder
- Somerset
- Sullivan
- Susquehanna
- Tioga
- Union
- Venango
- Warren
- Washington
- Wayne
- Westmoreland
- Wyoming
- York
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.