Aetna Medicare Assure Plan (HMO POS D SNP)

The Aetna Medicare Assure Plan is a Medicare Advantage Special Needs Plan (SNP) designed specifically for individuals who are eligible for both Medicare and Medicaid (dualeligible). It operates as an HMOPOS (Health Maintenance Organization with a PointofService option), giving members a primary care network while still allowing limited outofnetwork care when needed.

Who Is This Plan Intended For?

• U.S. residents aged 65 or older who are enrolled in both Medicare PartA and PartB.
• Individuals who also receive benefits from Medicaid (dualeligible).
• People who need coordinated care for chronic conditions, limited income, or limited resources.

Key Features

1. Comprehensive Coverage

The plan bundles Medicare PartA (hospital insurance), PartB (medical insurance), and usually PartD (prescription drug coverage) into a single benefit. This simplifies billing and reduces the chance of gaps in coverage.

2. HMO POS Design

Members have a primary care physician (PCP) who coordinates most of their care. When a PCP refers a member to a specialist, the visit is covered at the innetwork rate. If a specialist is outofnetwork, the plan may still pay a portion of the costs, though at a higher member share.

3. Low OutofPocket Costs

Because Medicaid helps cover premiums, deductibles, and copayments, most members experience very low or $0 monthly premiums and minimal costsharing for doctor visits, hospital stays, and prescription drugs.

4. Prescription Drug Coverage (PartD)

The plan includes a formulary that covers most generic and brandname drugs. Tiered copayments are usually low, and many medications required for chronic conditions are covered at the $0 tier.

5. Care Management Services

Members receive personalized case management, medication therapy management, and wellness programs aimed at reducing hospitalizations and improving quality of life.

Benefits Overview

• Medical Services: Hospital stays, skilled nursing facility care, home health, and outpatient services.
• Preventive Care: Annual wellness visits, vaccinations, screenings, and dental/vision/hearing benefits (often limited).
• Pharmacy Benefits: Access to a large network of pharmacies, mailorder options, and an 8step appeals process for denied drugs.
• Transportation: Nonemergency medical transportation to eligible appointments.
• Health & Wellness Programs: Fitness classes, nutrition counseling, and diseasespecific education.
• Telehealth: Virtual visits with PCPs and specialists, especially useful for mobilitylimited members.

How to Enroll

Enrollment is typically done during the annual Medicare Open Enrollment Period (Oct15Dec7) or during a Special Enrollment Period triggered by a change in Medicaid status. To enroll:

1. Confirm eligibility for both Medicare and Medicaid.
2. Contact Aetnas enrollment line or visit the Aetna Medicare website.
3. Provide personal information (Social Security number, Medicaid ID, Medicare number) and answer healthstatus questions.
4. Choose a primary care physician from the plans network.
5. Review the Summary of Benefits and Coverage (SBC) before signing.

Cost Summary (Typical for DualEligible Members)

Item	Typical Member Cost
Monthly Premium	$0 (covered by Medicaid)
Annual Deductible	$0
Primary Care Visit	$0$5
Specialist Visit (Innetwork)	$0$10
Emergency Room (Nonadmitted)	$0$20
Hospital Stay (Inpatient)	$0 (costs covered by Medicaid)
Prescription Drugs	$0$10 per prescription (most generics)

Network Considerations

The plans network is geographically based. Members must select a PCP who practices within the plans service area. While outofnetwork care is possible, it may require prior authorization and higher costsharing, so its best to stay within the network whenever possible.

Appeals and Grievances

Members have the right to appeal coverage decisions. Aetna provides a 5step appeals process:

1. Internal (red) appeal request reconsideration from Aetna.
2. External (yellow) appeal Medicare Administrative Law Judge review.
3. Further review by the Medicare Appeals Council (blue).
4. Federal court review (if necessary).

For assistance, call the Aetna Member Services line (found on the back of the member ID card).

Pros and Cons

Pros

• Low or no premiums and minimal costsharing for dualeligible members.
• Allinone coverage (medical, hospital, drug) simplifies management.
• Strong care coordination and casemanagement services.
• Access to extra benefits like transportation and wellness programs.

Cons

• Must use the plans network for most services; limited outofnetwork options.
• Plan availability varies by countymay not be offered everywhere.
• Formulary restrictions may require prior authorization for certain drugs.

How This Plan Compares to Traditional Medicare

Traditional Medicare (PartsA&B) does not include prescription drug coverage, has higher outofpocket costs for many services, and does not provide the coordinated care programs found in an SNP. For dualeligible beneficiaries, the Assure Plan often results in lower overall spending and better health outcomes because Medicaid supplements any remaining costs.

Frequently Asked Questions

Q: Do I need to stay on the plan for the entire year?

A: You can change plans during the Open Enrollment Period or if you qualify for a Special Enrollment Period (e.g., moving to a new service area).

Q: What happens if I travel out of my plans service area?

A: Emergency care is covered nationwide. For nonemergency services, you may need to seek prior authorization and may incur higher costsharing.

Q: Can I keep my current doctor?

A: Only if the doctor participates in the Aetna Assure network. You can search the provider directory online or call member services for assistance.

Q: Are dental, vision, and hearing covered?

A: Some plans include limited dental, vision, and hearing benefits; coverage varies by county. Review the SBC for exact details.

Contact Information

Aetna Medicare Member Services
Phone: 18005551234
Website: www.aetna.com/medicare
MondayFriday, 8am8pm local time