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Aetna Medicare Signature (PPO) H5521-375 - H5521-375-000
$0.00
Monthly Premium
Aetna Medicare Signature (PPO) H5521-375 is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-375-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Rhode Island 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 additional benefits Original Medicare doesn’t cover.
Learn more about Rhode Island 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 | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $700.00 |
| Out-of-pocket maximum | $7,150.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care doctor visit | In-Network $0 Out-of-Network 40% |
| Specialty doctor visit | In-Network $0 for services provided in a nursing home $60 for services provided outside a nursing home Out-of-Network 40% |
| Inpatient hospital care | In-Network $395 per day, days 1-7; $0 per day, days 8-90 Out-of-Network 40% per stay |
| Urgent care | Urgent Care: Copayment for Urgent Care $50 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $130 Maximum Plan Benefit of $250,000 |
| Emergency room visit | $130 If you are admitted to the hospital within 24 hours your cost share may be waived |
| Ambulance transportation | In-Network $300 Out-of-Network $300 |
Health Care Services and Medical Supplies
Aetna Medicare Signature (PPO) H5521-375 covers a range of additional benefits. Learn more about Aetna Medicare Signature (PPO) H5521-375 benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network 0% for continuous glucose monitors (CGM) at participating providers 0% for Accu-Chek/Roche and TRUE/Trividia blood glucose meters (BGM) and medical diabetic supplies 20% for blood glucose meters (BGM) and supplies manufactured by providers other than Accu-Chek/Roche and TRUE/Trividia with an approved prior authorization Out-of-Network 0% for Accu-Chek/Roche and TRUE/Trividia blood glucose meters (BGM) and medical diabetic supplies 40% for blood glucose meters (BGM) and supplies manufactured by providers other than Accu-Chek/Roche and TRUE/Trividia with an approved prior authorization 40% for continuous glucose monitors (CGM) |
| Durable medical equipment (DME) | In-Network 25% Out-of-Network 40% |
| Diagnostic tests, lab and radiology services, and X-rays | Lab Services: In-Network $0 for Hemoglobin A1C tests $10 for other lab services Out-of-Network 40% Diagnostic Procedures: In-Network $0 for certain Medicare-covered diagnostic tests and services including Retinal fundus, Spirometry, Peripheral arterial disease (PAD) $45 for other diagnostic procedures and tests Out-of-Network 40% Imaging: In-Network Xray: $15 CT Scans: $200 for services performed at a non-hospital facility; $275 for services performed at a hospital facility Diagnostic Radiology other than CT Scans: $200 for services performed at a non-hospital facility; $275 for services performed at a hospital facility Diagnostic Radiology Mammogram: $0 Out-of-Network 40% |
| Home health care | In-Network $0 Out-of-Network 40% |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $336 per day for days 1 to 7 $0 per day for days 8 to 90 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | In-Network $50 for Mental Health - Group Sessions $50 for Mental Health - Individual Sessions $50 for Psychiatric Services - Group Sessions $50 for Psychiatric Services - Individual Sessions Out-of-Network 40% for Mental Health Services- Group Sessions 40% for Mental Health Services - Individual Sessions 40% for Psychiatric Services - Group Sessions 40% for Psychiatric Services - Individual Sessions |
| Outpatient services/surgery | Ambulatory Surgical Center: In-Network $0 for preventive and diagnostic colonoscopy $285 all other ambulatory surgical center services Out-of-Network 40% |
| Outpatient substance abuse care | Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% |
| Podiatry services | Out-of-Network: Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 40% |
| Skilled Nursing Facility (SNF) care | In-Network $10 per day, days 1-20; $219 per day, days 21-100 Out-of-Network 25% per stay |
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 x-rays Out-of-Network Preventive dental services: 50% for oral exams 50% for cleanings 50% for x-rays Frequencies vary by covered dental service. |
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 $60 for all other Medicare-covered eye exams $0 for non-Medicare covered routine eye exam with an EyeMed network provider Eyewear: $0 for Medicare-covered prescription eyewear $100 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: 40% for Medicare-covered eye exams $0 for non-Medicare covered routine eye exam (out of network covered up to $50) Eyewear: 40% for Medicare-covered prescription eyewear $100 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 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: $60 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-$1,700 for hearing aids (Maximum two hearing aids every year) Out-of-Network: Hearing Exams: 40% for Medicare-covered hearing exams 40% for 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 for all preventive services covered under Original Medicare Out-of-Network 0% for the pneumonia, influenza, Hepatitis B, and Covid-19 vaccines 40% for all other preventive services covered under Original Medicare |
When reviewing Rhode Island 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 Rhode Island 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 |
Rhode Island Counties Served
We offer plans from Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, HealthspringSM or Kaiser Permanente.