In-network
Inpatient hospital
Days 1–7 $300 / day
Days 8–90 $0 / day
Total of listed copays · 7 charged days $2,100
Out-of-network
Tier 1: 50% coinsurance
Point of service
Not separately reported
● CMS 2027 plan record
Allina Health Aetna Medicare Eagle (PPO)
Choose and order benefitsSelections are saved only on this device.
Emergency transport
Ambulance
Ground · in-network$295 copay
Air · in-network20% coinsurance
Emergency services
Emergency room
$130 copay
Waived if admitted within 24 hours
Medical maximum
Maximum out-of-pocket
In-network$5,500
Combined in + out$8,000
Skilled care at home
Home health
In-network$0 copay
Out-of-network50% coinsurance
Monthly cost
Premium & giveback
Part C premium$0 / month
Consolidated C + DNot reported
CMS reports a Part B premium reduction of $135 per month.
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Primary care physician
In: Primary Care Physician Services: $0 copay · Out: 7a: 50% coinsurance
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Specialist
In: Physician Specialist Services: $45 copay · Out: 7d: 50% coinsurance
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Preventive care
In: Annual Physical Exam: $0 copay; Kidney Disease Education Services: 20% coinsurance; Glaucoma Screening: $0 copay; Diabetes Self-Management Training: $0 copay; Digital Rectal Exams: $0 copay; EKG following Welcome Visit: $0 copay · Out: 14b: 50% coinsurance; 14d: 50% coinsurance; 14e1: 50% coinsurance; 14e2: 50% coinsurance; 14e4: 50% coinsurance; 14e5: 50% coinsurance; 14a: 0%–50% coinsurance
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Diagnostic procedures & tests
In: Diagnostic Procedures/Tests: $0–$30 copay · Out: 8a1: 50% coinsurance
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Laboratory services
In: Lab Services: $0 copay · Out: 8a2: 50% coinsurance
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X-rays & standard imaging
In: Outpatient X-Ray Services: $25 copay · Out: 8b3: 50% coinsurance
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MRI, CT & PET imaging
In: Diagnostic Radiological Services: $0–$250 copay · Out: 8b1: 50% coinsurance
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Urgent care
In: Urgently Needed Services: $45 copay · Out: Not separately reported
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Emergency room
In: $130 copay · Out: Not separately reported
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Ground ambulance
In: $295 copay · Out: $295 copay
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Air ambulance
In: 20% coinsurance · Out: 20% coinsurance
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Outpatient hospital
In: Outpatient Hospital Services: $0–$350 copay; Observation Services: $300 copay · Out: 9a1: 50% coinsurance; 9a2: 50% coinsurance
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Outpatient surgery / ASC
In: Ambulatory Surgical Center (ASC) Services: $0–$300 copay · Out: 9b: 50% coinsurance
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Home health
In: $0 copay · Out: 50% coinsurance
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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: Skilled nursing facility: Tier 1: 50% coinsurance
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Cardiac & pulmonary rehabilitation
In: Cardiac Rehabilitation Services: $15 copay; Intensive Cardiac Rehabilitation Services: $15 copay; Pulmonary Rehabilitation Services: $10 copay; SET for PAD Services: $25 copay; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable · Out: 3-1: 50% coinsurance; 3-2: 50% coinsurance; 3-3: 50% coinsurance; 3-4: 50% coinsurance
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Occupational therapy
In: Occupational Therapy Services: $45 copay · Out: 7c: 50% coinsurance
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Physical & speech therapy
In: Physical Therapy and Speech-Language Pathology Services: $45 copay · Out: 7i: 50% coinsurance
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Mental health services
In: Partial Hospitalization Program: $55 copay; Individual Sessions for Mental Health Specialty Services: $0 copay; Group Sessions for Mental Health Specialty Services: $0 copay; Individual Sessions for Psychiatric Services: $0 copay; Group Sessions for Psychiatric Services: $0 copay; Inpatient psychiatric hospital: Tier 1: $300 / day for days 1–7; $0 / day for days 8–90 · Out: 5a: 50% coinsurance; 7e1: 50% coinsurance; 7e2: 50% coinsurance; 7h1: 50% coinsurance; 7h2: 50% coinsurance; Inpatient psychiatric hospital: Tier 1: 50% coinsurance
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Substance use treatment
In: Intensive Outpatient Program Services: $55 copay; Individual Sessions for Outpatient Substance Abuse: $0 copay; Group Sessions for Outpatient Substance Abuse: $0 copay · Out: 5b: 50% coinsurance; 9c1: 50% coinsurance; 9c2: 50% coinsurance
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Podiatry
In: Podiatry Services: $45 copay; 7f(NMC): $45 copay · Out: 7f: 50% coinsurance; 7f_2: 50% coinsurance
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Chiropractic
In: Chiropractic Services: $15 copay · Out: 7b: 50% coinsurance
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Dental
In: Medicare Dental Services: $45 copay; 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: 16a: 50% coinsurance; 16b1: 20% coinsurance; 16b2: 20% coinsurance; 16b3: 20% coinsurance; 16b4: 20% coinsurance; 16b5: 20% coinsurance; 16b6: 20% coinsurance; 16c1: 20% coinsurance; 16c2: 20% coinsurance; 16c3: 20% coinsurance; 16c4: 20% coinsurance; 16c7: 20% coinsurance; 16c8: 20% coinsurance; 16c10: 20% coinsurance
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Vision
In: Eye Exams: $0 copay; 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: 17a: 50% coinsurance; 17a1: $0 copay; 17a2: 50% coinsurance; 17b: 50% coinsurance; 17b1: $0 copay; 17b2: $0 copay; 17b3: $0 copay; 17b4: $0 copay; 17b5: $0 copay
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Hearing
In: Hearing Exams: $45 copay; 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: 18a: 50% coinsurance; 18a1: 50% coinsurance; 18a2: 50% coinsurance; 18b1: $0 copay
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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: 14c4: $0 copay
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Over-the-counter allowance
In: Over-the-Counter (OTC) Items: $0 copay · Out: 13b: $0 copay
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Meals
In: Meal Benefit: $0 copay · Out: 13c: $0 copay
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-network7a: 50% coinsurance
Specialist
In-networkPhysician Specialist Services: $45 copay
Out-of-network7d: 50% coinsurance
Preventive care
In-networkAnnual Physical Exam: $0 copay; Kidney Disease Education Services: 20% coinsurance; Glaucoma Screening: $0 copay; Diabetes Self-Management Training: $0 copay; Digital Rectal Exams: $0 copay; EKG following Welcome Visit: $0 copay
Out-of-network14b: 50% coinsurance; 14d: 50% coinsurance; 14e1: 50% coinsurance; 14e2: 50% coinsurance; 14e4: 50% coinsurance; 14e5: 50% coinsurance; 14a: 0%–50% coinsurance
Diagnostics & imaging4 benefits
Diagnostic procedures & tests
In-networkDiagnostic Procedures/Tests: $0–$30 copay
Out-of-network8a1: 50% coinsurance
Laboratory services
In-networkLab Services: $0 copay
Out-of-network8a2: 50% coinsurance
X-rays & standard imaging
In-networkOutpatient X-Ray Services: $25 copay
Out-of-network8b3: 50% coinsurance
MRI, CT & PET imaging
In-networkDiagnostic Radiological Services: $0–$250 copay
Out-of-network8b1: 50% coinsurance
Urgent & hospital care6 benefits
Urgent care
In-networkUrgently Needed Services: $45 copay
Out-of-networkNot separately reported
Emergency room
In-network$130 copay
Out-of-networkNot separately reported
Ground ambulance
In-network$295 copay
Out-of-network$295 copay
Air ambulance
In-network20% coinsurance
Out-of-network20% coinsurance
Outpatient hospital
In-networkOutpatient Hospital Services: $0–$350 copay; Observation Services: $300 copay
Out-of-network9a1: 50% coinsurance; 9a2: 50% coinsurance
Outpatient surgery / ASC
In-networkAmbulatory Surgical Center (ASC) Services: $0–$300 copay
Out-of-network9b: 50% coinsurance
Recovery & therapy5 benefits
Home health
In-network$0 copay
Out-of-network50% coinsurance
Skilled nursing facility
In-networkSkilled nursing facility: Tier 1: $0 / day for days 1–20; $221 / day for days 21–100
Out-of-networkSkilled nursing facility: Tier 1: 50% coinsurance
Cardiac & pulmonary rehabilitation
In-networkCardiac Rehabilitation Services: $15 copay; Intensive Cardiac Rehabilitation Services: $15 copay; Pulmonary Rehabilitation Services: $10 copay; SET for PAD Services: $25 copay; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable
Out-of-network3-1: 50% coinsurance; 3-2: 50% coinsurance; 3-3: 50% coinsurance; 3-4: 50% coinsurance
Occupational therapy
In-networkOccupational Therapy Services: $45 copay
Out-of-network7c: 50% coinsurance
Physical & speech therapy
In-networkPhysical Therapy and Speech-Language Pathology Services: $45 copay
Out-of-network7i: 50% coinsurance
Behavioral health2 benefits
Mental health services
In-networkPartial Hospitalization Program: $55 copay; Individual Sessions for Mental Health Specialty Services: $0 copay; Group Sessions for Mental Health Specialty Services: $0 copay; Individual Sessions for Psychiatric Services: $0 copay; Group Sessions for Psychiatric Services: $0 copay; Inpatient psychiatric hospital: Tier 1: $300 / day for days 1–7; $0 / day for days 8–90
Out-of-network5a: 50% coinsurance; 7e1: 50% coinsurance; 7e2: 50% coinsurance; 7h1: 50% coinsurance; 7h2: 50% coinsurance; Inpatient psychiatric hospital: Tier 1: 50% coinsurance
Substance use treatment
In-networkIntensive Outpatient Program Services: $55 copay; Individual Sessions for Outpatient Substance Abuse: $0 copay; Group Sessions for Outpatient Substance Abuse: $0 copay
Out-of-network5b: 50% coinsurance; 9c1: 50% coinsurance; 9c2: 50% coinsurance
Specialty care2 benefits
Podiatry
In-networkPodiatry Services: $45 copay; 7f(NMC): $45 copay
Out-of-network7f: 50% coinsurance; 7f_2: 50% coinsurance
Chiropractic
In-networkChiropractic Services: $15 copay
Out-of-network7b: 50% coinsurance
Supplemental benefits7 benefits
Dental
In-networkMedicare Dental Services: $45 copay; 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-network16a: 50% coinsurance; 16b1: 20% coinsurance; 16b2: 20% coinsurance; 16b3: 20% coinsurance; 16b4: 20% coinsurance; 16b5: 20% coinsurance; 16b6: 20% coinsurance; 16c1: 20% coinsurance; 16c2: 20% coinsurance; 16c3: 20% coinsurance; 16c4: 20% coinsurance; 16c7: 20% coinsurance; 16c8: 20% coinsurance; 16c10: 20% coinsurance
Vision
In-networkEye Exams: $0 copay; 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-network17a: 50% coinsurance; 17a1: $0 copay; 17a2: 50% coinsurance; 17b: 50% coinsurance; 17b1: $0 copay; 17b2: $0 copay; 17b3: $0 copay; 17b4: $0 copay; 17b5: $0 copay
Hearing
In-networkHearing Exams: $45 copay; 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-network18a: 50% coinsurance; 18a1: 50% coinsurance; 18a2: 50% coinsurance; 18b1: $0 copay
Transportation
Not applicableIn-network10b(NMC): Not applicable
Out-of-networkNot separately reported
Fitness & wellness
In-networkFitness Benefit: $0 copay
Out-of-network14c4: $0 copay
Over-the-counter allowance
In-networkOver-the-Counter (OTC) Items: $0 copay
Out-of-network13b: $0 copay
Meals
In-networkMeal Benefit: $0 copay
Out-of-network13c: $0 copay
Plan costs & rulesCoverage overview
Premium & Part B giveback
$0 Part C premium / month · CMS reports a Part B premium reduction of $135 per month.
Maximum out-of-pocket (MOOP)
In-network$5,500
Combined in + out$8,000
Medical deductibles
In-networkNot reported
Out-of-networkNot reported
Annual health deductible
$0
Combined network deductible
Not separately reported
Part D premium
Not reported
Network & referrals
Local PPO · Referrals: Not required · Out-of-network coverage: Yes
Prescription drugs0 tiers
Part D deductible
Not reported
Using this plan
Understand H3219-005-000
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
Allina Health Aetna Medicare Eagle (PPO) is a 2027 Local PPO offered by Allina Health Aetna Medicare in Twin Cities Metro and Select MN Counties. The CMS record indicates out-of-network coverage, although member costs may differ from in-network care. The plan record does not require referrals. Its listed inpatient copay stages total $2,100 across 7 charged days.
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: $45 copay
- Laboratory services
- Lab Services: $0 copay
Separate visits or services; costs are not added together.
Tests & outpatient care
- Diagnostic procedures & tests
- Diagnostic Procedures/Tests: $0–$30 copay
- MRI, CT & PET imaging
- Diagnostic Radiological Services: $0–$250 copay
- Outpatient hospital
- Outpatient Hospital Services: $0–$350 copay; Observation Services: $300 copay
The service setting and billing details can change what you pay.
Emergency & hospital care
- Emergency room
- $130 copay
- Listed inpatient stages
- $2,100 total
7 charged inpatient days are included in the calculated total. 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 a Part B premium reduction of $135 per month.
Availability
Who can enroll
- Service area
- Twin Cities Metro and Select MN Counties (MN)
- Plan type
- Local PPO
- Contract / plan
- H3219-005
- Coverage year
- 2027
Enrollment generally requires Medicare eligibility and residence in the plan's 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: $45 copay; 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 copay; 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: $45 copay; 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
MealsMeal Benefit: $0 copay
Plan-specific answers
Frequently asked questions
Where is H3219-005-000 available?
Allina Health Aetna Medicare Eagle (PPO) is listed for Twin Cities Metro and Select MN Counties (MN). Enrollment generally requires Medicare eligibility and residence in the plan's service area.
What is the in-network maximum out-of-pocket limit for H3219-005-000?
The 2027 CMS record lists an in-network medical maximum out-of-pocket limit of $5,500. Prescription drug spending generally does not count toward this medical limit.
What is the monthly plan premium for H3219-005-000?
The listed Part C premium is $0 per month. This does not replace the standard Medicare Part B premium.
What does an emergency room visit cost on H3219-005-000?
The plan record lists $130 copay, waived when an admission meets the plan's stated timing rule.
Does H3219-005-000 report extra benefits?
Yes. CMS reports dental, vision, hearing, over-the-counter allowance, fitness & wellness, and other supplemental benefits. See the detailed benefit rows and official plan documents for limits and conditions.
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 H3219-005-000 fits
- Full CMS plan ID
H3219-005-000- Contract
H3219- Base plan code
H3219-005- Segment
000- Carrier
- Allina Health Aetna Medicare
- Plan type
- Local PPO
- Service area
- Twin Cities Metro and Select MN Counties (MN)
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.
- Anoka, MN
- Blue Earth, MN
- Carver, MN
- Chisago, MN
- Dakota, MN
- Hennepin, MN
- Isanti, MN
- Kanabec, MN
- Le Sueur, MN
- Ramsey, MN
- Scott, MN
- Steele, MN
3 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 15 county links
Minnesota
- Anoka County, Minnesota
- Blue Earth County, Minnesota
- Carver County, Minnesota
- Chisago County, Minnesota
- Dakota County, Minnesota
- Hennepin County, Minnesota
- Isanti County, Minnesota
- Kanabec County, Minnesota
- Le Sueur County, Minnesota
- Ramsey County, Minnesota
- Scott County, Minnesota
- Steele County, Minnesota
- Waseca County, Minnesota
- Washington County, Minnesota
- Wright County, Minnesota
About this code
What H3219-005-000 identifies
H3219-005-000 is a Contract Year 2027 Medicare plan segment code. Searches written as H3219-005, H3219 005, or the compact full CMS ID H3219005000 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.