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Aetna Medicare Longevity (HMO I-SNP) - H0628-018-000

na* for plan year 2025

$39.30

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: H0628-018-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$39.30

Monthly Premium

Ohio 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 Ohio 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

CoverageDetails
Monthly plan premium$39.30
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 visitIn-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 transportation20%

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).

CoverageDetails
Chiropractic servicesIn-Network:

Chiropractic Services:
Coinsurance for Medicare-covered Chiropractic Services 20%
Prior Authorization Required for Chiropractic Services
Diabetes supplies, training, nutrition therapy and monitoringIn-Network|20%
Durable medical equipment (DME)In-Network|20%
Diagnostic tests, lab and radiology services, and X-raysLab 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 careIn-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $0
Prior Authorization Required for Psychiatric Hospital Services
Mental health outpatient careIn-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/surgeryAmbulatory Surgical Center: In-Network|0% for preventive and diagnostic colonoscopy|20% all other ambulatory surgical center services
Outpatient substance abuse careIn-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$290 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 servicesIn-Network:

Podiatry Services:
Coinsurance for Medicare-Covered Podiatry Services 20%
Copayment for Routine Foot Care $0
  • Maximum 6 visits every year
Prior Authorization Required for Podiatry Services
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.

CoverageDetails
Dental careIn-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

CoverageDetails
Vision careIn-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.

CoverageDetails
Hearing careIn-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.

CoverageDetails
Preventive services and health/wellness education programsIn-Network|$0 copay for all preventive services covered under Original Medicare

When reviewing Ohio 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 Ohio 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

Ohio Counties Served

We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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