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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 Upstate NY Area: HV, Capital, CNY, WNY. 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 $40.20. 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 deductible for prescription drugs. After the deductible, you'll pay the costs for your drugs based on the drug tier and the pharmacy you use. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for Part D covered drugs. If you qualify for the low-income subsidy, your monthly Part D premium will be $40.20.
Additional Benefits
The Aetna Medicare Assure QMB (HMO D-SNP) plan offers a range of benefits, including coverage for inpatient and outpatient services. Many services have no copay, such as ambulance, emergency, and home health services, as well as preventive services. The plan includes additional benefits such as dental, vision, and hearing services, with varying cost-sharing structures like coinsurance and copays. The plan also covers home infusion, dialysis, medical equipment, and diagnostic services.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, both requiring prior authorization; Inpatient Hospital-Acute has a copay of $2,185 per admission or stay, while Inpatient Hospital Psychiatric has a copay of $2,036 per admission or stay. Additional Days for Inpatient Hospital-Acute are also 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 under the Aetna Medicare Assure QMB (HMO D-SNP) plan. Outpatient hospital and observation services have a 20% coinsurance, and outpatient blood services have a 20% coinsurance with a waived three-pint deductible; outpatient substance abuse services have a minimum 20% and maximum 20% coinsurance.
Partial Hospitalization See details
Partial Hospitalization is covered by 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, with no copay for any services. Ground and air ambulance services have a 20% coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Aetna Medicare Assure QMB (HMO D-SNP) plan. Emergency services have a $110 copay and no coinsurance, while urgently needed services have a $45 copay and no coinsurance. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation have no copay and no coinsurance.
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 and Speech-Language Pathology Services have a 20% coinsurance. Occupational Therapy Services, Mental Health Specialty Services, Psychiatric Services, and Opioid Treatment Program Services have a minimum 20% coinsurance, and a maximum 20% coinsurance. Other Health Care Professional services have a coinsurance between 0% and 20%. Additional Telehealth Benefits have no copay. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
Preventive Services include an annual physical exam with no copay, and other services such as Health Education, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, Remote Access Technologies, Home and Bathroom Safety Devices and Modifications, Wigs for Hair Loss Related to Chemotherapy, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit are covered, but may require a 20% coinsurance. In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Enhanced Disease Management, Telemonitoring Services, and Counseling Services are not covered.
Hearing Services See details
Hearing Services include routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Routine hearing exams have no copay and a 20% coinsurance, and fitting/evaluation for hearing aids have no copay. Prescription Hearing Aids (all types) have a maximum copay of $1700, while Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, and Prescription Hearing Aids - Over the Ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include coverage for eye exams with a 20% coinsurance, and routine eye exams and other eye exam services have no copay. Eyewear is partially covered, but contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are covered, with a 20% coinsurance for Medicare dental services. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable & fixed), maxillofacial prosthetics, implant services, and oral and maxillofacial surgery have no copay. Orthodontics is not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by the Aetna Medicare Assure QMB (HMO D-SNP) plan. The plan requires prior authorization and has a coinsurance of 20%.
Medical Equipment See details
Medical Equipment benefits are covered, including Durable Medical Equipment, Prosthetics/Medical Supplies, and Diabetic Equipment. Durable Medical Equipment has a 20% coinsurance and requires authorization, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance, and Diabetic Supplies have no coinsurance, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including all diagnostic and radiological services, Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services. There is no copay for these services, and the coinsurance is at most 20% for Diagnostic Procedures/Tests, Lab Services, Therapeutic Radiological Services, and Outpatient X-Ray Services. The coinsurance is at most 20%, with a minimum of 0%, for Diagnostic Radiological Services.
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, but Additional Hours of Care and Personal Care Services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Aetna Medicare Assure QMB (HMO D-SNP) plan, but the specific services, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services, are not covered. There is coinsurance for the covered services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but the plan does not provide SNF services as a supplemental benefit under Part C, and additional days beyond Medicare-covered SNF and non-Medicare-covered SNF stays are not covered. Prior authorization is required, and the cost sharing is the same as Original Medicare.
Other Services See details
Other services include coverage for over-the-counter items with no copay, and a meal benefit with no copay. Acupuncture, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and other services are not covered.
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