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Hospital coverage

What you need to know about: Emergency Rooms & Hospitalization Coverage

How do I find out if my hospital is covered under the Aetna Medicare Advantage PPO plan?

There are over 4,200 network hospitals nationwide with excellent coverage in areas where city retirees live. All hospitals in the downstate New York area are in network. As of Sept. 1, Stony Brook University Hospital will be in network. Memorial Sloan Kettering and the Hospital for Special Surgery are both in network. All other facilities in the Hudson Valley to the D.C. Capitol Region are also in network.

There are 193 contracted hospitals in Florida; 95% statewide. 100% of the hospitals are in network in the Florida counties where most retirees live: Miami-Dade, Broward, Palm Beach, Hernando, Manatee, Pasco & Pinella counties.

Aetna has 109 contracted hospitals in North Carolina; 96% statewide. No large hospital systems are out of network. In Charlotte and Wake Counties, where most city retirees live, 100% of hospitals are in network, including Duke Health and the Carolina Center for Specialty Surgery.

The Cleveland Clinic is in network. Currently, the Mayo Clinic is not in network, and only sees patients on a case-by-case basis. Aetna will work with members to try and get access to Mayo, and if they refuse, Aetna will assist with finding another provider.

You can also visit Aetna’s dedicated website to check if a hospital is in network.

Are Memorial Sloan Kettering (MSK) and the Hospital for Special Surgery (HSS) in network?

Yes. Aetna signed contracts with both hospitals and they are in network. Individual doctors employed by both hospitals are also in network.

What is the coverage for emergency room visits?

  • Emergency care worldwide: $50 (waived if admitted)
  • Urgently needed care worldwide: $15
  • Hospital/mental health/inpatient hospital care: $0 in 2023; As of 2024: $300 per admission / $750 max
  • Ambulance: $0

Do I need the 365-day hospital rider?

No, the Aetna Medicare Advantage PPO plan fully covers the cost of hospitalizations outside the patient’s copay.

What are “urgently needed” services and how do they differ from emergency services?

Urgently needed services are covered under this plan and are provided when network providers are temporarily unavailable or inaccessible or when the enrollee is out of the service area. For example, you may need immediate care during the weekend. Services must be immediately needed and medically necessary.

What if I am hospitalized during the transition to the Aetna Medicare Advantage PPO plan?

Aetna will send out a Continuity of Care assistance form to all members to allow retirees to tell Aetna about any services they are currently receiving, and Aetna will honor services that are ongoing. To help manage your care during the implementation of the new plan, you will receive information on how to contact Aetna, so a nurse case manager can be assigned to answer all your questions and assist you during this transition.