Copays and deductibles

What you need to know about: Plan copays and deductibles

What are my out-of-pocket costs, including deductibles, copays and coinsurance, on the Aetna Medicare Advantage PPO plan?

$0 deductible in 2023, an annual $150 deductible will apply as of Jan. 1, 2024, lower than the $276 deductible for GHI Senior Care.
$0-$15 copay for most services
$0 for primary care doctor visits; $15 for specialists
$0 for Medicare-covered preventive services
$0 outpatient services $1,500 annual maximum out-of-pocket amount. With GHI Senior Care, there was no cap on out-of-pocket costs.
Hospital/mental health/inpatient hospital care: $0 in 2023; As of 2024: $300 per admission / $750 maximum annually
Emergency care worldwide: $50 (waived if admitted)
Urgently needed care worldwide: $15 Ambulance: $0 (before members had a $25 deductible and a $2,500 annual benefit maximum, and this maximum was also combined with Durable Medical Equipment and Private Duty Nursing. After the maximum is met, the member would have had to pay 100% of the cost)
Inpatient substance abuse: $0 in 2023; As of 2024: $300 per admission / $750 maximum annually

Also see the comparison chart between GHI Senior Care and the Aetna Medicare Advantage PPO plan which lists many of Aetna's costs for services.

Are there any out-of-pocket maximums?

$1,500 is the maximum out-of-pocket annual amount (under GHI Senior Care, by contrast, there was no maximum cap on out-of-pocket costs to protect retirees).

What is the coverage for preventive care services, such as vaccines, cancer screenings, etc.?

All Medicare-covered preventive services (for a full list see the Centers for Medicare) have a $0 copay for both in and out-of-network providers. Primary care physician visits have a zero copay. Vaccines covered under Medicare Part B vaccines are cost-free. These include the annual influenza vaccine, COVID-19 vaccines, pneumococcal shots and Hepatitis B.

Medicare plans cannot charge for any covered Medicare Part D vaccine as a result of the Inflation Reduction Act of 2022. As of Jan. 1, 2023, recommended Part D vaccines eligible for the $0 cost include:

Hepatitis A
Hepatitis A and Hepatitis B
Human Papillomavirus (HPV)
Measles, Mumps and Rubella (MMR)
Meningococcal Tetanus and Diphtheria Toxoids
Varicella (Chickenpox)
Zoster (Shingles)

What is the coverage for medical procedures, surgeries & hospital stays?

$0 for outpatient surgery
Hospital/mental health/inpatient hospital care: $0 in 2023; As of 2024: $300 per admission / $750 maximum annually
Other procedures range from $0-$15

See more about hospital coverage in our FAQ section.

Do my deductible and copay costs apply to my out-of-pocket maximum?

Yes, for medical services, but prescription drug costs do not apply towards the maximum.

I have already met my deductible for this year. Will I have to meet another deductible when the city enrolls me in the new Aetna Medicare Advantage PPO plan on Sept. 1, 2023?

No. You will not have to meet another deductible. You will only be responsible for your doctor copays. However, an annual deductible of $150 will apply as of Jan. 1, 2024.

Does the Aetna Medicare Advantage PPO have a lifetime limit?

No, this plan does not have a lifetime limit.