In-network
Inpatient hospital
Per admission $2,241 per stay
Out-of-network
Not separately reported
Point of service
Not separately reported
● CMS 2027 plan record
Aetna Medicare Chronic Care Total (HMO C-SNP)
Choose and order benefitsSelections are saved only on this device.
Emergency transport
Ambulance
Ground · in-network20% coinsurance
Air · in-network20% coinsurance
Emergency services
Emergency room
$115 copay
Waived if admitted within 24 hours
Medical maximum
Maximum out-of-pocket
In-network$9,850
Combined in + outNot reported
Skilled care at home
Home health
In-network$0 copay
Out-of-networkNot separately reported
Monthly cost
Premium & giveback
Part C premium$0 / month
Consolidated C + D$0 / month
CMS reports no Part B premium reduction for this plan.
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Primary care physician
In: Primary Care Physician Services: $0 copay · Out: Not separately reported
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Specialist
In: Physician Specialist Services: 0%–20% coinsurance · Out: Not separately reported
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Preventive care
In: Annual Physical Exam: $0 copay; Kidney Disease Education Services: 20% coinsurance; Glaucoma Screening: 20% coinsurance; Diabetes Self-Management Training: 20% coinsurance; Digital Rectal Exams: 20% coinsurance; EKG following Welcome Visit: 20% coinsurance · Out: Not separately reported
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Diagnostic procedures & tests
In: Diagnostic Procedures/Tests: 0%–20% coinsurance · Out: Not separately reported
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Laboratory services
In: Lab Services: 0%–20% coinsurance · Out: Not separately reported
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X-rays & standard imaging
In: Outpatient X-Ray Services: 20% coinsurance · Out: Not separately reported
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MRI, CT & PET imaging
In: Diagnostic Radiological Services: 0%–20% coinsurance · Out: Not separately reported
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Urgent care
In: Urgently Needed Services: $40 copay · Out: Not separately reported
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Emergency room
In: $115 copay · Out: Not separately reported
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Ground ambulance
In: 20% coinsurance · Out: Not separately reported
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Air ambulance
In: 20% coinsurance · Out: Not separately reported
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Outpatient hospital
In: Outpatient Hospital Services: 0%–20% coinsurance; Observation Services: 20% coinsurance · Out: Not separately reported
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Outpatient surgery / ASC
In: Ambulatory Surgical Center (ASC) Services: 0%–20% coinsurance · Out: Not separately reported
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Home health
In: $0 copay · Out: Not separately reported
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Skilled nursing facility
In: Skilled nursing facility: Tier 1: $0 / day for days 1–20; $221 / day for days 21–100 · Out: Not separately reported
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Cardiac & pulmonary rehabilitation
In: Cardiac Rehabilitation Services: $0 copay; Intensive Cardiac Rehabilitation Services: $0 copay; Pulmonary Rehabilitation Services: 20% coinsurance; SET for PAD Services: 20% coinsurance; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable · Out: Not separately reported
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Occupational therapy
In: Occupational Therapy Services: 20% coinsurance · Out: Not separately reported
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Physical & speech therapy
In: Physical Therapy and Speech-Language Pathology Services: 20% coinsurance · Out: Not separately reported
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Mental health services
In: Partial Hospitalization Program: 20% coinsurance; Individual Sessions for Mental Health Specialty Services: 20% coinsurance; Group Sessions for Mental Health Specialty Services: 20% coinsurance; Individual Sessions for Psychiatric Services: 20% coinsurance; Group Sessions for Psychiatric Services: 20% coinsurance; Inpatient psychiatric hospital: Tier 1: $2,091 per stay · Out: Not separately reported
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Substance use treatment
In: Intensive Outpatient Program Services: 20% coinsurance; Individual Sessions for Outpatient Substance Abuse: 20% coinsurance; Group Sessions for Outpatient Substance Abuse: 20% coinsurance · Out: Not separately reported
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Podiatry
In: Podiatry Services: $0 copay; 7f(NMC): $0 copay · Out: Not separately reported
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Chiropractic
In: Chiropractic Services: 20% coinsurance · Out: Not separately reported
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Dental
In: Medicare Dental Services: 20% coinsurance; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 copay; Dental X-Rays: $0 copay; Other Diagnostic Dental Services: $0 copay; Prophylaxis (Cleaning): $0 copay; Fluoride Treatment: $0 copay; Other Preventive Dental Services: $0 copay; Restorative Services: $0 copay; Endodontics: $0 copay; Periodontics: $0 copay; Prosthodontics, removable: $0 copay; Prosthodontics, fixed: $0 copay; Oral and Maxillofacial Surgery: $0 copay; Adjunctive General Services: $0 copay · Out: Not separately reported
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Vision
In: Eye Exams: 0%–20% coinsurance; Routine Eye Exams: $0 copay; Other Eye Exam Services: $0 copay; Eyewear: $0 copay; Contact Lenses: $0 copay; Eyeglasses (lenses and frames): $0 copay; Eyeglass lenses: $0 copay; Eyeglass frames: $0 copay; Upgrades: $0 copay · Out: Not separately reported
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Hearing
In: Hearing Exams: 20% coinsurance; Routine Hearing Exams: $0 copay; Fitting/Evaluation for Hearing Aid: $0 copay; Prescription Hearing Aids (all types): $0 copay; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable · Out: Not separately reported
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Transportation
In: 10b(NMC): Not applicable · Out: Not separately reported
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Fitness & wellness
In: Fitness Benefit: $0 copay · Out: Not separately reported
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Over-the-counter allowance
In: Over-the-Counter (OTC) Items: $0 copay · Out: Not separately reported
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Meals
In: Meal Benefit: Not applicable · Out: Not separately reported
Plan details
All plan benefits
No benefits match that search.
Medical care3 benefits
Primary care physician
In-networkPrimary Care Physician Services: $0 copay
Out-of-networkNot separately reported
Specialist
In-networkPhysician Specialist Services: 0%–20% coinsurance
Out-of-networkNot separately reported
Preventive care
In-networkAnnual Physical Exam: $0 copay; Kidney Disease Education Services: 20% coinsurance; Glaucoma Screening: 20% coinsurance; Diabetes Self-Management Training: 20% coinsurance; Digital Rectal Exams: 20% coinsurance; EKG following Welcome Visit: 20% coinsurance
Out-of-networkNot separately reported
Diagnostics & imaging4 benefits
Diagnostic procedures & tests
In-networkDiagnostic Procedures/Tests: 0%–20% coinsurance
Out-of-networkNot separately reported
Laboratory services
In-networkLab Services: 0%–20% coinsurance
Out-of-networkNot separately reported
X-rays & standard imaging
In-networkOutpatient X-Ray Services: 20% coinsurance
Out-of-networkNot separately reported
MRI, CT & PET imaging
In-networkDiagnostic Radiological Services: 0%–20% coinsurance
Out-of-networkNot separately reported
Urgent & hospital care6 benefits
Urgent care
In-networkUrgently Needed Services: $40 copay
Out-of-networkNot separately reported
Emergency room
In-network$115 copay
Out-of-networkNot separately reported
Ground ambulance
In-network20% coinsurance
Out-of-networkNot separately reported
Air ambulance
In-network20% coinsurance
Out-of-networkNot separately reported
Outpatient hospital
In-networkOutpatient Hospital Services: 0%–20% coinsurance; Observation Services: 20% coinsurance
Out-of-networkNot separately reported
Outpatient surgery / ASC
In-networkAmbulatory Surgical Center (ASC) Services: 0%–20% coinsurance
Out-of-networkNot separately reported
Recovery & therapy5 benefits
Home health
In-network$0 copay
Out-of-networkNot separately reported
Skilled nursing facility
In-networkSkilled nursing facility: Tier 1: $0 / day for days 1–20; $221 / day for days 21–100
Out-of-networkNot separately reported
Cardiac & pulmonary rehabilitation
In-networkCardiac Rehabilitation Services: $0 copay; Intensive Cardiac Rehabilitation Services: $0 copay; Pulmonary Rehabilitation Services: 20% coinsurance; SET for PAD Services: 20% coinsurance; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable
Out-of-networkNot separately reported
Occupational therapy
In-networkOccupational Therapy Services: 20% coinsurance
Out-of-networkNot separately reported
Physical & speech therapy
In-networkPhysical Therapy and Speech-Language Pathology Services: 20% coinsurance
Out-of-networkNot separately reported
Behavioral health2 benefits
Mental health services
In-networkPartial Hospitalization Program: 20% coinsurance; Individual Sessions for Mental Health Specialty Services: 20% coinsurance; Group Sessions for Mental Health Specialty Services: 20% coinsurance; Individual Sessions for Psychiatric Services: 20% coinsurance; Group Sessions for Psychiatric Services: 20% coinsurance; Inpatient psychiatric hospital: Tier 1: $2,091 per stay
Out-of-networkNot separately reported
Substance use treatment
In-networkIntensive Outpatient Program Services: 20% coinsurance; Individual Sessions for Outpatient Substance Abuse: 20% coinsurance; Group Sessions for Outpatient Substance Abuse: 20% coinsurance
Out-of-networkNot separately reported
Specialty care2 benefits
Podiatry
In-networkPodiatry Services: $0 copay; 7f(NMC): $0 copay
Out-of-networkNot separately reported
Chiropractic
In-networkChiropractic Services: 20% coinsurance
Out-of-networkNot separately reported
Supplemental benefits7 benefits
Dental
In-networkMedicare Dental Services: 20% coinsurance; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 copay; Dental X-Rays: $0 copay; Other Diagnostic Dental Services: $0 copay; Prophylaxis (Cleaning): $0 copay; Fluoride Treatment: $0 copay; Other Preventive Dental Services: $0 copay; Restorative Services: $0 copay; Endodontics: $0 copay; Periodontics: $0 copay; Prosthodontics, removable: $0 copay; Prosthodontics, fixed: $0 copay; Oral and Maxillofacial Surgery: $0 copay; Adjunctive General Services: $0 copay
Out-of-networkNot separately reported
Vision
In-networkEye Exams: 0%–20% coinsurance; Routine Eye Exams: $0 copay; Other Eye Exam Services: $0 copay; Eyewear: $0 copay; Contact Lenses: $0 copay; Eyeglasses (lenses and frames): $0 copay; Eyeglass lenses: $0 copay; Eyeglass frames: $0 copay; Upgrades: $0 copay
Out-of-networkNot separately reported
Hearing
In-networkHearing Exams: 20% coinsurance; Routine Hearing Exams: $0 copay; Fitting/Evaluation for Hearing Aid: $0 copay; Prescription Hearing Aids (all types): $0 copay; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable
Out-of-networkNot separately reported
Transportation
Not applicableIn-network10b(NMC): Not applicable
Out-of-networkNot separately reported
Fitness & wellness
In-networkFitness Benefit: $0 copay
Out-of-networkNot separately reported
Over-the-counter allowance
In-networkOver-the-Counter (OTC) Items: $0 copay
Out-of-networkNot separately reported
Meals
Not applicableIn-networkMeal Benefit: Not applicable
Out-of-networkNot separately reported
Plan costs & rulesCoverage overview
Premium & Part B giveback
$0 Part C premium / month · CMS reports no Part B premium reduction for this plan.
Maximum out-of-pocket (MOOP)
In-network$9,850
Combined in + outNot reported
Medical deductibles
In-networkNot reported
Out-of-networkNot reported
Annual health deductible
Not separately reported
Combined network deductible
Not separately reported
Part D premium
$0 / month
Network & referrals
HMO · Referrals: Not required · Out-of-network coverage: Not reported
Prescription drugs5 tiers
Part D deductible
$700 / year
Drug tier 1
Standard retail: $0 copay · Preferred retail: $0 copay · 30-day supply
Drug tier 2
Standard retail: $0 copay · Preferred retail: $0 copay · 30-day supply
Drug tier 3
Standard retail: 9% coinsurance · Preferred retail: 9% coinsurance · 30-day supply
Drug tier 4
Standard retail: 25% coinsurance · Preferred retail: 25% coinsurance · 30-day supply
Drug tier 5
Standard retail: 25% coinsurance · Preferred retail: 25% coinsurance · 30-day supply
Using this plan
Understand H0628-031-000
Plain-language context built from this plan’s 2027 CMS record. It is a guide to the reported benefits, not a personalized cost estimate.
Plan at a glance
A quick read on this plan
Aetna Medicare Chronic Care Total (HMO C-SNP) is a 2027 HMO offered by Aetna Medicare in Greater Cleveland Area. The plan record does not require referrals.
Common benefit costs
What you may pay
These are individual in-network benefit amounts. A real visit may involve more than one separately billed service.
Routine care
- Primary care physician
- Primary Care Physician Services: $0 copay
- Specialist
- Physician Specialist Services: 0%–20% coinsurance
- Laboratory services
- Lab Services: 0%–20% coinsurance
Separate visits or services; costs are not added together.
Tests & outpatient care
- Diagnostic procedures & tests
- Diagnostic Procedures/Tests: 0%–20% coinsurance
- MRI, CT & PET imaging
- Diagnostic Radiological Services: 0%–20% coinsurance
- Outpatient hospital
- Outpatient Hospital Services: 0%–20% coinsurance; Observation Services: 20% coinsurance
The service setting and billing details can change what you pay.
Emergency & hospital care
- Emergency room
- $115 copay
Actual costs depend on the care received and plan rules.
Helpful context
Terms worth knowing
Maximum out-of-pocket (MOOP)
This is the most you generally pay during the plan year for covered Part A and Part B medical services under the applicable network limit. Premiums and prescription drug costs generally do not count toward it.
Part B premium reduction (“giveback”)
A giveback may reduce the amount you pay toward Medicare Part B; it is not usually paid to you as cash. The CMS record notes: CMS reports no Part B premium reduction for this plan.
Availability
Who can enroll
- Service area
- Greater Cleveland Area (OH)
- Plan type
- HMO
- Special Needs Plan
- Chronic or Disabling Condition
- Contract / plan
- H0628-031
- Coverage year
- 2027
This is a Chronic or Disabling Condition; enrollment requires the plan's specific eligibility criteria as well as residence in its service area. Confirm eligibility and the exact service area with the plan before enrolling.
Supplemental coverage
Extra benefits reported
Availability is summarized here; allowances, frequency limits, networks, and prior-authorization rules may apply.
DentalMedicare Dental Services: 20% coinsurance; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 copay; Dental X-Rays: $0 copay; Other Diagnostic Dental Services: $0 copay; Prophylaxis (Cleaning): $0 copay; Fluoride Treatment: $0 copay; Other Preventive Dental Services: $0 copay; Restorative Services: $0 copay; Endodontics: $0 copay; Periodontics: $0 copay; Prosthodontics, removable: $0 copay; Prosthodontics, fixed: $0 copay; Oral and Maxillofacial Surgery: $0 copay; Adjunctive General Services: $0 copay
VisionEye Exams: 0%–20% coinsurance; Routine Eye Exams: $0 copay; Other Eye Exam Services: $0 copay; Eyewear: $0 copay; Contact Lenses: $0 copay; Eyeglasses (lenses and frames): $0 copay; Eyeglass lenses: $0 copay; Eyeglass frames: $0 copay; Upgrades: $0 copay
HearingHearing Exams: 20% coinsurance; Routine Hearing Exams: $0 copay; Fitting/Evaluation for Hearing Aid: $0 copay; Prescription Hearing Aids (all types): $0 copay; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable
Over-the-counter allowanceOver-the-Counter (OTC) Items: $0 copay
Fitness & wellnessFitness Benefit: $0 copay
Plan-specific answers
Frequently asked questions
Where is H0628-031-000 available?
Aetna Medicare Chronic Care Total (HMO C-SNP) is listed for Greater Cleveland Area (OH). This is a Chronic or Disabling Condition; enrollment requires the plan's specific eligibility criteria as well as residence in its service area.
What is the in-network maximum out-of-pocket limit for H0628-031-000?
The 2027 CMS record lists an in-network medical maximum out-of-pocket limit of $9,850. Prescription drug spending generally does not count toward this medical limit.
What is the monthly plan premium for H0628-031-000?
The listed consolidated Part C and Part D premium is $0 per month. This does not replace the standard Medicare Part B premium.
What does an emergency room visit cost on H0628-031-000?
The plan record lists $115 copay, waived when an admission meets the plan's stated timing rule.
Does H0628-031-000 report extra benefits?
Yes. CMS reports dental, vision, hearing, over-the-counter allowance, fitness & wellness. See the detailed benefit rows and official plan documents for limits and conditions.
Carrier-hosted source material
Official plan documents
An exact direct document has not been verified for this plan yet. Use the carrier's document finder and confirm H0628-031-000 before relying on a document.
Source trail
Official CMS, Contract Year 2027
Plan identity and benefits come from CMS PBP data. Benefits and drug cost sharing come from the approved annual PBP tabular extract and its CMS dictionary. Premiums and drug deductibles are cross-checked with the annual Landscape. Geography comes from annual PlanArea and PlanRegionArea records, including exact segments and partial-county or employer/group qualifiers. Quick-reference values should be confirmed in current official plan documents.
Plan context
Where H0628-031-000 fits
- Full CMS plan ID
H0628-031-000- Contract
H0628- Base plan code
H0628-031- Segment
000- Carrier
- Aetna Medicare
- Plan type
- HMO
- Service area
- Greater Cleveland Area (OH)
County/service-area foundation
CMS service-area entries
Service areas come from the annual CMS PlanArea and PlanRegionArea tables for this exact contract, plan, and segment. Partial-county and employer/group qualifiers remain part of the coverage area. Regional PPO county entries use the matching annual Landscape expansion of the CMS region.
- Ashland, OH
- Ashtabula, OH
- Belmont, OH
- Carroll, OH
- Columbiana, OH
- Cuyahoga, OH
- Geauga, OH
- Harrison, OH
- Holmes, OH
- Jefferson, OH
- Lake, OH
- Lorain, OH
9 additional service-area entries are retained in the data record.
Exact county navigation
Counties with exact segment geography
These links are limited to named counties tied to this exact medical plan segment. Partial-county entries remain labeled for verification.
Show 21 county links
Ohio
- Ashland County, Ohio
- Ashtabula County, Ohio
- Belmont County, Ohio
- Carroll County, Ohio
- Columbiana County, Ohio
- Cuyahoga County, Ohio
- Geauga County, Ohio
- Harrison County, Ohio
- Holmes County, Ohio
- Jefferson County, Ohio
- Lake County, Ohio
- Lorain County, Ohio
- Mahoning County, Ohio
- Medina County, Ohio
- Portage County, Ohio
- Richland County, Ohio
- Stark County, Ohio
- Summit County, Ohio
- Trumbull County, Ohio
- Tuscarawas County, Ohio
- Wayne County, Ohio
About this code
What H0628-031-000 identifies
H0628-031-000 is a Contract Year 2027 Medicare plan segment code. Searches written as H0628-031, H0628 031, or the compact full CMS ID H0628031000 refer to this plan or its base plan code.
Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.