Aetna Medicare Value Plan (HMO)

What Is a Medicare HMO?

An HMO (Health Maintenance Organization) is a type of Medicare Advantage (Part C) plan that contracts with a specific network of doctors, hospitals, and other healthcare providers. Enrollees receive all covered services through that network, with the exception of emergency or urgent care situations. The Aetna Medicare Value Plan (HMO) follows this model, offering the same Medicare benefits as Original Medicare plus additional perks such as drug coverage, vision, hearing, and dental.

Plan Overview

• Plan type: Medicare Advantage HMO
• Provider: Aetna Health, a subsidiary of CVS Health
• Geographic availability: Offered in select states and territories; see Aetnas website for a zipcode lookup.
• Core Medicare coverage: Part A (hospital) and Part B (medical) services.
• Additional coverage: Prescription drug (Part D), vision, hearing, dental, fitness memberships, and telehealth.

Eligibility & Enrollment

You must be eligible for Medicare Part A and enrolled in Part B. The plan is available to anyone who lives in the plans service area, with no additional medical underwriting required. Enrollment periods include:

• Initial Enrollment Period (IEP): The 7month window that begins three months before you turn 65.
• Annual Election Period (AEP): October 15 December 7 each year.
• Special Enrollment Periods (SEP): Qualifying life events such as moving to a new service area, loss of other coverage, or changes in eligibility.

Key Benefits

Medical Coverage

• Innetwork hospital stays, skillednursing facility care, and emergency services.
• Primary care physician (PCP) coordination you choose a PCP who manages referrals to specialists.
• Preventive services at no additional cost (e.g., annual wellness visit, flu shots).

Prescription Drug Coverage

The plan includes a formulary that covers most generic and brandname drugs. Tiered copayments reduce costs for common medications, and a mailorder option is available for maintenance drugs.

Additional Perks

• Dental: Two routine cleanings per year and up to $150 in annual orthodontic coverage for eligible adults.
• Vision: Annual eye exam, plus up to $150 toward glasses or contacts.
• Hearing: One free hearing exam and a $100 allowance for hearing aid accessories.
• Fitness: Membership to Aetnas Fit for Life program, which includes discounts at participating gyms.
• Telehealth: Virtual visits with PCPs and specialists, available 24/7.

Costs & Copayments

Exact costs vary by county, but typical figures for the 2024 plan year are:

Service	Typical Copayment
Primary Care Visit	$0$15
Specialist Visit (innetwork)	$25$40
Emergency Room (nonadmitted)	$150
Hospital Admission	$0 (deductible may apply)
Prescription Tier 1 (generic)	$0$5
Prescription Tier 2 (preferred brand)	$15$30
Prescription Tier 3 (nonpreferred brand)	$40$70

Most enrollees also pay a modest monthly premium, often ranging from $0 to $30, depending on the county. The plan includes an outofpocket maximum (OOPM) of $4,950 for 2024, after which the plan pays 100% of covered services.

Provider Network

The Aetna Medicare Value Plan (HMO) requires you to use innetwork providers for all nonemergency care. The network is built around a hierarchy of primarycare physicians, specialists, hospitals, and outpatient facilities. You can locate providers using Aetnas online directory or mobile app. Features include:

• Search by location, specialty, or language spoken.
• Ratings and patient reviews for many providers.
• Ability to schedule appointments directly from the portal.

If you need a specialist, your PCP must submit a referral. The referral process is usually completed within 12 business days.

Whats Covered?

Hospital & Inpatient Services

All Medicarecovered inpatient services, including room and board, nursing care, and medically necessary supplies, are covered when you stay at an innetwork hospital.

Outpatient & Physician Services

Primary, specialist, and preventive services are fully covered after you meet the applicable copayment. This includes lab work, xrays, and diagnostic imaging.

Home Health & Hospice

Qualified home health services (e.g., skilled nursing, physical therapy) and hospice care are covered when ordered by a physician and provided by an innetwork agency.

Emergency & Urgent Care

Emergency care is covered regardless of network status, but youll pay the innetwork copayment amount if you go to a nonnetwork ER. Urgent care must be innetwork to receive the standard copayment.

Prescription Drugs

The plans formulary includes over 4,000 medicines. Tiered pricing encourages the use of generics. Mailorder is available for 90day supplies of chroniccondition drugs.

Dental, Vision, & Hearing

Routine exams, cleanings, and basic services are covered. For major procedures (e.g., crowns, dentures), the plan provides a fixed annual allowance.

OutofArea Care

If you travel outside the plans service area, you may receive emergency care at any hospital, but routine care must be sought from an innetwork provider in the new location. Aetna offers a network of trusted outofarea providers in many popular vacation destinations; you can find them through the plans Travel Care tool.

How to Enroll

1. Visit Aetnas Medicare page and enter your ZIP code.
2. Review plan details, premium, and network information.
3. Click Enroll Now and follow the prompts to create an account or sign in.
4. Provide your Medicare card number, Social Security number, and current address.
5. Confirm your selection and review the Summary of Benefits.
6. Submit the enrollment; you will receive a welcome packet within 10business days.

If you need assistance, Aetnas enrollment counselors are available MondayFriday, 8am8pm EST at 18007991000.

How It Compares to Other Medicare Options

When deciding between Original Medicare, other Medicare Advantage plans, or the Aetna Medicare Value Plan (HMO), consider the following factors:

Feature	Aetna Medicare Value Plan (HMO)	Original Medicare + Medigap	Other Medicare Advantage (PPO)
Network Flexibility	Innetwork only (except emergencies)	No network restrictions	Innetwork preferred, some outofnetwork coverage
Additional Benefits	Dental, vision, hearing, fitness, telehealth	Typically not included (must purchase separate plans)	Varies; many include at least vision or dental
Monthly Premium	$0$30 (varies by county)	Medigap premiums can be $100$250+	Similar to Aetna or slightly higher
OutofPocket Maximum	$4,950 (2024)	No OOPM (limits on what Medicare pays)	Usually $6,000$7,550
Prescription Drug Coverage	Included	Separate Part D plan needed	Usually included

Frequently Asked Questions

1. Can I see a doctor outside the network?

Only for emergencies. For nonemergency care, you must use innetwork providers or obtain a referral for outofnetwork services, which may be denied.

2. What happens if I miss a PCP appointment?

Missing a scheduled PCP visit does not affect your coverage, but you may need to reschedule to maintain continuity of care and obtain any required referrals.

3. Are there any extra fees for telehealth?

Telehealth visits are covered with the same copayment as an innetwork office visit, typically $0$15.

4. How does the plan handle preexisting conditions?

Because it is a Medicare Advantage plan, preexisting conditions are covered as long as you are eligible for Medicare Part A and B. No medical underwriting is required.

5. Can I change my plan after enrollment?

Yes. During the Annual Election Period (Oct15Dec7) you can switch to another Medicare Advantage plan, a different Aetna plan, or revert to Original Medicare.

6. What if I move to a new ZIP code?

If the plan is offered in your new area, you can enroll during a Special Enrollment Period triggered by the move. If not, you must choose a different Medicare Advantage plan that serves your new location.

7. Does the plan cover overthecounter (OTC) items?

Some OTC items are covered under the plans Wellness Allowance, which provides a yearly stipend (often $100) that can be used for eligible health products.

8. How are hospital readmissions handled?

Readmissions within 30 days for the same condition are generally covered without additional copayment, subject to network rules.

9. Is there a waiting period for certain services?

Most services are available immediately after enrollment. However, some supplemental benefits (e.g., dental major work) may have a 12month waiting period.

10. Who can I contact for help with claims?

Call Aetnas Member Services at 18007991000 (MondayFriday, 8am8pm EST) or use the secure messaging feature in the online portal.

Choosing the right Medicare plan is a personal decision that depends on your health needs, budget, and preferred way of receiving care. The Aetna Medicare Value Plan (HMO) offers a balance of low premiums, an outofpocket maximum, and a suite of extra benefits that can make it an attractive option for seniors who value coordinated care within a single network.