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Aetna Medicare Assure QMB (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Assure QMB (HMO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Assure QMB (HMO D-SNP) in 2025, please refer to our full plan details page.
Aetna Medicare Assure QMB (HMO D-SNP) is a HMO D-SNP plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Greater Rochester Area. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Aetna Medicare Assure QMB (HMO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Aetna Medicare Assure QMB (HMO D-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Aetna Medicare Assure QMB (HMO D-SNP).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Aetna Medicare Assure QMB (HMO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $57.40. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $590.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $9350.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Aetna Medicare Assure QMB (HMO D-SNP) plan has a $590.00 deductible for prescription drugs. After you meet your deductible, you will pay the costs associated with your drugs as outlined in the plan's formulary. Once your total drug costs reach $2000.00, you enter the Catastrophic Coverage Phase, where you pay nothing for Part D covered drugs. This plan's premium is $57.40 with the LIS subsidy.
Additional Benefits
The Aetna Medicare Assure QMB (HMO D-SNP) plan offers a wide range of benefits. This plan includes coverage for inpatient and outpatient services, with copays and coinsurance varying by service. Emergency, primary care, and preventive services are covered, with some services having no copay. This plan also includes coverage for hearing, vision, and dental services. Additionally, you'll find benefits for home infusion, dialysis, medical equipment, and diagnostic services. The plan also covers home health services, and cardiac rehabilitation.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with a copay of $2,185.00 and $2,036.00, respectively, per admission or stay. Additional Days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stays and Upgrades for Inpatient Hospital-Acute and Additional Days and Non-Medicare-covered Stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient hospital and observation services have a 20% coinsurance, while outpatient blood services also have a 20% coinsurance. Individual and group sessions for outpatient substance abuse services have a coinsurance between 20% and 20%.
Partial Hospitalization See details
Partial Hospitalization is covered under the Aetna Medicare Assure QMB (HMO D-SNP) plan, but requires prior authorization. You will pay 20% coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Aetna Medicare Assure QMB (HMO D-SNP) plan. Ground and air ambulance services have a 20% coinsurance, while transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered by the Aetna Medicare Assure QMB (HMO D-SNP), with a $110 copay, and no coinsurance. Urgently Needed Services have a $45 copay, and no coinsurance. Worldwide Emergency Services are also covered, with no copay for Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation.
Primary Care See details
The Aetna Medicare Assure QMB (HMO D-SNP) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, other health care professional, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Primary care physician services, chiropractic services, physician specialist services, and physical therapy have a 20% coinsurance, while additional telehealth benefits have no copay. Routine chiropractic care is not covered.
Preventive Services See details
Preventive Services include an annual physical exam with no copay, and additional preventive services, including health education, wigs for hair loss, additional smoking cessation counseling, fitness benefits, remote access technologies, and home and bathroom safety devices, which have a $0 copay. Kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following welcome visits have a 20% coinsurance.
Hearing Services See details
Hearing services are covered, including hearing exams and prescription hearing aids. Routine hearing exams have no copay and a 20% coinsurance, while fitting/evaluation for a hearing aid has no copay. Prescription hearing aids (all types) have a maximum copay of $1700, while inner ear, outer ear, and over the ear hearing aids are not covered. OTC hearing aids are also not covered.
Vision Services See details
Vision services include eye exams with a 20% coinsurance, and routine eye exams and other eye exam services with no copay. Eyewear is covered with a 20% coinsurance, but contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are covered under the Aetna Medicare Assure QMB (HMO D-SNP) plan, and include Medicare Dental Services with 20% coinsurance and other dental services with no copay for many services. Orthodontics is not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, Medicare Part B Chemotherapy/Radiation Drugs with 0-20% coinsurance, and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered under the Aetna Medicare Assure QMB (HMO D-SNP) plan, but require prior authorization. The coinsurance for these services is between 20% and 20%.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. Durable Medical Equipment has a 20% coinsurance with no copay, while Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies have a 20% coinsurance with no copay, and Diabetic Supplies have no coinsurance and no copay. Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Aetna Medicare Assure QMB (HMO D-SNP) plan. Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services have a coinsurance of at most 20%, and there is no copay.
Home Health Services See details
Home Health Services are covered by the Aetna Medicare Assure QMB (HMO D-SNP) plan with no copay and no coinsurance. Additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Aetna Medicare Assure QMB (HMO D-SNP) plan, but the plan does not cover any of the sub-services. There is coinsurance for some services, but the specific amount is not provided.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but additional days beyond Medicare-covered SNF stays and non-Medicare-covered SNF stays are not covered. This plan requires prior authorization for SNF services, and the copay information is available in the plan details.
Other Services See details
Other Services in the Aetna Medicare Assure QMB (HMO D-SNP) plan covers Over-the-Counter (OTC) Items with no copay, and a maximum benefit coverage amount of $15.00 every month, but acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered. The plan also covers meal benefits and Other 1 and Other 2 services with no copay.
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