Aetna medicare hmo and ppo disclosure

Aetna MedicareSM Plan (HMO) and
Aetna MedicareSM Plan (PPO)
Note: Medicare Advantage plan requirements govern and supersede
any state or general disclosures contained within.
Plan Benefi ts
Member Cost Sharing
Covered services include most types of treatment Cost sharing refers to the portion of medical provided by primary care physicians, specialists services that you pay out of your own pocket. and hospitals. However, the health plan does Refer to your plan documents to see which of exclude and/or include limits on coverage for the following cost-sharing provisions apply to some services, including but not limited to, cosmetic surgery and experimental procedures. • Copay — This may be a fl at fee that you pay In addition, in order to be covered, all services, directly to the health care provider at the time including the location (type of facility), duration and costs of services, must be medically necessary • Coinsurance — This is a percentage of the as defi ned below and as determined by Aetna. fees that you must pay toward the cost of The information that follows provides general some covered medical expenses. Your health information regarding Aetna health plans. For a care provider will bill you for this amount.
complete description of the benefi ts available to • Calendar Year Deductible — The amount you, including procedures to follow, exclusions of covered medical expenses you pay each and limitations, refer to your specifi c plan calendar year before benefi ts are paid. There documents, which may include the Summary is a calendar-year deductible that applies to of Benefi ts, Evidence of Coverage and any applicable riders and amendments to your plan.
• Inpatient Hospital Deductible — The amount of covered inpatient hospital expenses you pay for each hospital confi nement before benefi ts are paid. This deductible is in addition to any other copayments or deductibles under your plan.
• Emergency Room Deductible — The amount of covered hospital emergency room expenses you pay each year before benefi ts are paid. A separate hospital emergency room deductible applies to each visit by a person to a hospital emergency room unless the person is admitted to the hospital as an inpatient within 24 hours after a visit to a hospital emergency room.
Your Primary Care Physician
If you do not get a referral when a referral is Check your plan documents to see if your plan required, you may have to pay the bill yourself, requires you to select a primary care physician or the service will be treated as nonpreferred if (PCP). If a PCP is required, you must choose your plan includes out-of-network benefi ts. a doctor from the Aetna network. You can look Some services may also require prior approval up network doctors in a printed Aetna Physician by us. See the Precertifi cation section and your Directory, or visit our DocFind® directory at www.aetnamedicare.com. If you do not
The following points are important to remember have Internet access and would like a printed directory, please contact Member Services at • The referral is how your PCP arranges for you the toll-free number on your ID card and request to be covered at the in-network benefi t level for necessary, appropriate specialty care and • You should discuss the referral with your indicate the name of the PCP you have chosen PCP to understand what specialist services are on your enrollment form. Or, call Member Services after you enroll to tell us your selection. • If the specialist recommends any additional The name of your PCP will appear on your treatments or tests beyond those referred by Aetna ID card. You may change your selected the PCP, you may need to get another referral PCP at any time. If you change your PCP, you from your PCP before receiving the services.
will receive a new ID card. Your PCP can provide • Except in emergencies, all inpatient hospital primary health care services as well as coordinate services require a prior referral from your your overall care. You should consult your PCP PCP and prior authorization by Aetna.
when you are sick or injured to help determine • Referrals are valid for one year as long as you the care that is needed. If your plan requires remain an eligible member of the plan; the referrals, your PCP should issue a referral to fi rst visit must be within 90 days of referral a participating specialist or facility for certain services. (See Referral Policy for details.) • In plans without out-of-network benefi ts, coverage for services from nonparticipating Referral Policy
providers requires prior authorization by Aetna Check your plan documents to see if your plan in addition to a special nonparticipating referral requires PCP referrals for specialty care. Your from the PCP. When properly authorized, these plan documents will also list any direct access services are fully covered, less the applicable benefi ts that do not require referrals. If referrals are required, you must see your PCP fi rst before • The referral (and a precertifi cation, if required) visiting a specialist or other outpatient provider provides that, except for applicable cost for nonemergency or nonurgent care. Your PCP sharing (that is, copays, coinsurance and/ will issue a referral for the services needed.
or deductibles), you will not have to pay the charges for covered expenses, as long as the individual seeking care is a member at the time the services are provided.
Direct Access
Group (PMG), an Integrated Delivery System (IDS) or a similar organization, your care must be coordinated through the IPA, the PMG or participating providers without a PCP referral, similar organization and the organization may subject to the terms and conditions of the plan and cost sharing requirements. Participating Precertifi cation
providers will be responsible for obtaining any required preauthorization of services from Aetna. If required by your plan, some health care Refer to your specifi c plan documents for details.
services, like hospitalization and certain outpatient surgery, require “precertifi cation.” Aetna Medicare PPO plans have direct-access This means the service must be approved by benefi ts. Direct-access benefi ts allow you to Aetna before it will be covered under the plan. directly access participating providers and Check your plan documents for a complete nonparticipating providers without a PCP list of services that require this approval. When referral, subject to additional cost sharing reviewing a precertifi cation request, we will verify requirements. Even so, you may be able to your eligibility and make sure the service is a reduce your out-of-pocket expenses considerably covered expense under your plan. We also check by using participating providers. Refer to your the cost-effectiveness of the service and we may specifi c plan brochure for details. If your plan communicate with your doctor if necessary. If does not specifi cally cover direct-access benefi ts you qualify, we may enroll you in one of our (self-referred or nonparticipating provider case management programs and have a nurse call benefi ts) and you go directly to a specialist or to make sure you understand your upcoming hospital for nonemergency or nonurgent care procedure. When you visit a doctor, hospital without a referral, you must pay the bill yourself or other provider that participates in the Aetna unless the service is specifi cally identifi ed as a network, someone at the provider’s offi ce will direct-access benefi t in your plan documents.
contact Aetna on your behalf to get the approval.
Direct Access Ob/Gyn Program
If your plan allows you to go outside the This program allows female members to visit, Aetna network of providers, you will have to without a referral, any participating obstetrician get that approval yourself. In this case, it is or gynecologist for a routine well-woman exam, your responsibility to make sure the service is including a breast exam, mammogram and a precertifi ed, so be sure to talk to your doctor Pap smear, and for obstetric or gynecologic about it. If you do not get proper authorization problems. Obstetricians and gynecologists may for out-of-network services, you may have to also refer a woman directly to other participating pay for the service yourself. You cannot request providers for covered obstetric or gynecologic precertifi cation after the service is performed. services. All health plan preauthorization and To precertify services, call the number shown coordination requirements continue to apply. If your Ob/Gyn is part of an Independent Practice Association (IPA), a Physician Medical Health Care Provider Network
Advance Directives
All hospitals may not be considered Aetna There are three types of advance directives: participating providers for all the services that • Durable power of attorney — appoints you need. Your physician can contact Aetna to someone you trust to make medical decisions identify a participating facility for your specifi c needs. Certain PCPs are affi liated with IDSs, • Living will — spells out the type and extent IPAs or other provider groups. If you select one of these PCPs you will generally be referred to • Do-not-resuscitate order — states that you specialists and hospitals within that system, don’t want to be given CPR if your heart stops association or group (“organization”). However, or be intubated if you stop breathing.
if your medical needs extend beyond the scope You can create an advance directive in several of the affi liated providers, you may request coverage for services provided by Aetna network providers that are not affi liated with the • Get an advance medical directive form from a organization. In order to be covered, services health care professional. Certain laws require provided by network providers that are not health care facilities that receive Medicare and affi liated with the organization may require Medicaid funds to ask all patients at the time prior authorization from Aetna and/or the IDS they are admitted if they have an advance or other provider groups. You should note that directive. You don’t need an advance directive other health care providers (e.g. specialists) to receive care. But we are required by law to may be affi liated with other providers through • Ask for an advance directive form at state or local offi ces on aging, bar associations, legal service programs, or your local health locate inpatient and outpatient services, partial hospitalization and other behavioral health care • Work with a lawyer to write an advance services, please visit our DocFind directory at www.aetna.com. If you do not have Internet
• Create an advance directive using computer access and would like a printed provider directory, please contact Member Services at the toll-free number on your Aetna ID card If you have Medicare coverage and you are not satisfi ed with the way Aetna handles advance directives, you can fi le a complaint with your Medicare State Certifi cation Agency. Visit www.medicare.gov for information on specifi c state agencies or call 1-800-MEDICARE (1-800-633-4227) (TTY/TDD: 1-877-486-2048).
Source: American Academy of Family Physicians. Advanced Directives and Do Not Resuscitate Orders. January 2009.
Available at http://familydoctor.org/003.
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Accessed February 20, 2009.
Transplants and Other
What to Do Outside Your
Complex Conditions
Aetna Medicare Service Area
Our National Medical Excellence Program® If you are traveling outside your Aetna Medicare and other specialty programs help you access service area; you are covered for emergency covered services for transplants and certain other and urgently needed care. Urgent care may complex medical conditions at participating be obtained from a private practice physician, facilities experienced in performing these services. a walk-in clinic, an urgent care center or an Depending on the terms of your plan of benefi ts, emergency facility. Certain conditions, such as you may be limited to only those facilities severe vomiting, earaches, sore throats or fever, participating in these programs when needing are considered “urgent care” outside your Aetna a transplant or other complex condition covered. Medicare service area and are covered in any of Note: There are exceptions depending on state If, after reviewing information submitted to us by the provider that supplied care, the nature of the Emergency Care
urgent or emergency problem does not qualify If you need emergency care, you are covered for coverage, it may be necessary to provide us 24 hours a day, 7 days a week, anywhere in with additional information. We will send you the world. An emergency medical condition an Emergency Room Notifi cation Report to is one manifesting itself by acute symptoms of complete, or a Member Services representative suffi cient severity such that a prudent layperson, can take this information by telephone.
who possesses average knowledge of health and medicine, could reasonably expect the absence Follow-up Care after Emergencies
of immediate medical attention to result in All follow-up care should be coordinated by serious jeopardy to the person's health, or with your PCP. Follow-up care with nonparticipating respect to a pregnant woman, the health of the providers is only covered with a referral from woman and her unborn child. Whether you are your PCP and prior authorization from Aetna. in or out of an Aetna service area, we simply ask Whether you were treated inside or outside your that you follow the guidelines below when you Aetna Medicare service area, if your plan requires referrals, you must obtain a referral before any • Call the local emergency hotline (ex. 911) or follow-up care can be covered. If your plan go to the nearest emergency facility. If a delay does not require referrals you should contact would not be detrimental to your health, call Aetna at the number on your ID card before your doctor or PCP. Notify your doctor or PCP care is received at non-network facilities. Suture as soon as possible after receiving treatment.
removal, cast removal, X-rays and clinic and • If you are admitted to an inpatient facility, you emergency room revisits are some examples of or a family member or friend on your behalf should notify your doctor, PCP or Aetna as PPO plans: All in-network and out-of-network follow-up care will be covered under the terms and conditions of your plan.
After-Hours Care
Covered nonformulary prescription drugs may You may call your provider’s offi ce 24 hours a be subject to higher copayments or coinsurance day, 7 days a week if you have medical questions under some benefi t plans. Some prescription or concerns. You may also consider visiting drug benefi t plans may exclude from coverage participating Urgent Care facilities. See your plan certain nonformulary drugs that are not listed documents for cost-sharing provisions for urgent on the preferred drug list. If it is medically necessary for you to use such drugs, your physician, you or your authorized representative Prescription Drugs
(or pharmacist in the case of antibiotics and If your plan covers outpatient prescription analgesics) may contact Aetna to request drugs, your plan may include a preferred coverage as a medical exception. Check your drug list (also known as a “drug formulary”). The preferred drug list includes prescription drugs that, depending on your prescription precertifi cation or step therapy before they drug benefi ts plan, are covered on a preferred will be covered under some prescription drug basis. Many drugs, including many of those benefi t plans. Step therapy is a different form listed on the preferred drug list, are subject to of precertifi cation that requires a trial of one rebate arrangements between Aetna and the or more “prerequisite therapy” medications manufacturer of the drugs. Such rebates are before a “step therapy” medication will be not refl ected in and do not reduce the amount covered. If it is medically necessary for you to you pay to your pharmacy for a prescription use a medication subject to these requirements drug. In addition, in circumstances where prior to completing the step therapy, your your prescription plan utilizes copayments or physician, you or your authorized representative coinsurance calculated on a percentage of the can request coverage of such drug as a medical cost of a drug or a deductible, it is possible for exception. Nonprescription drugs and drugs your cost to be higher for a preferred drug than in the Limitations and Exclusions section of the plan documents (received and/or available For information regarding how medications are upon enrollment) are not covered, and medical reviewed and selected for the preferred drug list, exceptions are not available for them.
please refer to www.aetnamedicare.com or the
Aetna Medicare Preferred Drug (Formulary)
Guide. Printed Preferred Drug Guide
information will be provided, upon request or
if applicable, annually for current members and
upon enrollment for new members. For more
information, call Member Services at the toll-free
number on your ID card. The medications listed
on the preferred drug list are subject to change
in accordance with applicable state law.
Behavioral Health Network
prescription drugs not yet reviewed for possible Behavioral health care services are managed addition to the preferred drug list are either by Aetna. As a result, Aetna is responsible for available at the highest copay under plans with making initial coverage determinations and an “open” formulary, or excluded from coverage coordinating referrals to the Aetna provider unless a medical exception is obtained under network. As with other coverage determinations, plans that use a “closed” formulary. These new you may appeal adverse behavioral health care drugs may also be subject to precertifi cation coverage determinations in accordance with the or step therapy. Ask your treating physician(s) about specifi c medications. Refer to your plan The type of behavioral health benefi ts available documents or contact Member Services for to you depends on the terms of your health information regarding terms, conditions and plan and state law. If your health plan includes limitations of coverage. If you use the Aetna behavioral health services, you may be covered Rx Home Delivery® mail order prescription for mental health conditions and/or drug and program or the Aetna Specialty Pharmacy® alcohol abuse services, including inpatient and specialty drug program, you will be acquiring outpatient services, partial hospitalizations these prescriptions through an affi liate of and other behavioral health services. You can Aetna. Aetna Rx Home Delivery's and Aetna determine the type of behavioral health coverage Specialty Pharmacy’s cost of purchasing drugs available under the terms of your plan and how takes into account discounts, credits and other to access services by calling the Aetna Member amounts they may receive from wholesalers, Services number listed on your ID card.
manufacturers, suppliers and distributors. The negotiated charge with Aetna Rx Home Delivery, If you have an emergency, call 911 or your local LLC. and Aetna Specialty Pharmacy may be emergency hotline, if available. For routine higher than the cost of purchasing drugs and services, access covered behavioral health services available under your health plan by the following methods: Updates to the Drug Formulary
• Call the toll-free Behavioral Health number For up-to-date formulary information, visit (where applicable) listed on your ID card www.aetnamedicare.com. If you do not have
or, if no number is listed, call the Member Services number listed on your ID card for the Services at the toll-free number on your ID card to fi nd out how a specifi c drug is covered.
• Where required by your plan, call your PCP for a referral to the designated behavioral health provider group.
You can access most outpatient therapy services without a referral or preauthorization. However, you should fi rst consult Member Services to confi rm that any such outpatient therapy services do not require a referral or preauthorization.
Behavioral Health Provider
How Aetna Pays In-Network
Safety Data Available
Providers
All the providers in our network directory are Health provider network safety data, visit independent. They are free to contract with www.aetna.com/docfi nd and select the
other health plans. Providers join our network “Get info on Patient Safety and Quality” link. by signing contracts with us. Or they work for If you do not have Internet access, you may organizations that have contracts with us. We call Member Services at the toll-free number pay network providers in many different ways. shown on your Aetna ID card to request a Sometimes we pay a rate for a specifi c service and sometimes for an entire course of care (for example, a fl at fee for a pregnancy without Behavioral Health Depression
complications). In certain circumstances, Prevention Programs
some providers are paid a pre-paid amount per Aetna Behavioral Health offers two prevention month per Aetna member (capitation). We may programs specifi cally for Medicare members also provide additional incentives to re ward and another that also includes commercial physicians for delivering cost-effective quality members. A depression screening and treatment care. We pay some network hospitals by the day referral component is available to any Medicare (per diem) and we pay others in a different way, such as a percentage of their standard billing • has been determined to be at high risk for rates. We encourage you to ask your providers complications due to a medical condition how they are paid for their services.
identifi ed based on an initial screening that How Aetna Pays Out-of-Network
is completed when entering the plan.
Providers
• has had a cardiac valve replacement.
• are already involved in one of the Aetna Some of our plans pay for services from providers Medical Disease Management programs.
who are not in our network. Many plans pay for
services based on what is called the “reasonable,”
“usual and customary” or “prevailing” charge.
Other plans pay based on our standard fees for
care received from a network provider, or based
on a percentage of Medicare’s fees. When we
pay less than what your provider charges, your
provider may require you to pay the difference.
This is true even if you have reached your
plan’s out-of-pocket maximum. Here is how
we fi gure out what we will pay for each type
of plan.
Prevailing Charge Plans
Step 3: We refer to your health plan. We pay our portion of the prevailing charge We get information from Ingenix, which is as listed in your health plan. You pay your owned by United HealthCare. Health plans portion (called “coinsurance”) and any send Ingenix copies of claims for services they deductible. For example, your out of network received from providers. The claims include the doctor charges $120 for an offi ce visit. Your date and place of the service, the procedure code, plan covers 70 percent of the “reasonable,” and the provider’s charge. Ingenix combines this “usual and customary” or “prevailing” charge. information into databases that show how much Let's say the prevailing charge is $100. And providers charge for just about any service in let's say you already met your deductible. Aetna would pay $70. You would pay the other $30. Your doctor may also bill you for the $20 Step 2: We calculate the portion we pay. difference between the prevailing charge ($100) For most of our health plans, we use the 80th and the billed charge ($120). In this case, your percentile to calculate how much to pay for doctor could bill you for a total of $50. The out-of-network services. Payment at the 80th Prevailing Charge Databases The New York percentile means 80 percent of charges in the State Attorney General (NYAG) investigated database are the same or less for that service in the confl icts of interest related to the ownership and use of Ingenix data. Under an agreement If there are not enough charges (less than 9) with the NYAG, UnitedHealth Group agreed in the databases for a service in a particular zip to stop using the Ingenix databases when an code, we may use “derived charge data” instead. independent database (not owned by a health “Derived charge data” is based on the charges insurer) is created. In a separate agreement with for comparable procedures, multiplied by a factor NYAG in January 2009, Aetna agreed to use that takes into account the relative complexity this new database when it is ready. We also will of the procedure that was performed. We also work with the new database owner to create use derived charge data for our student health online tools to give you better information plans and Aetna Affordable Health Choices® about the cost of your care when using providers plans. We also may consider other factors to determine what to pay if a service is unusual or not performed often in your area. These factors can include:• The complexity of the service• The degree of skill needed• The provider’s specialty• The prevailing charge in other areas• Aetna’s own data Fee Schedule Plans
Exceptions
Step 1: We compare the provider’s bill to our fee Some “prevailing charge” plans set the prevailing charge at a different percentile. For some Your plan may say that we will pay the provider claims (like those from hospitals and outpatient based on our fee schedule for network doctors, centers) we may use other information and data or a certain percentage of that fee schedule, or sources to determine the charge. And some a certain percentage of what Medicare pays. of our plans pay based on a different kind of For example, your plan may say we pay 125 fee schedule. Also, for some non-participating percent of what we pay a network doctor for the providers we may pay based on other contractual arrangements. Our provider claims codes and payment policies may also affect what we pay Let’s say you have your appendix removed.
for a claim. Aetna may use computer software Our network rate for that surgery is $1,600. (including ClaimCheck®) and other tools to We multiply $1,600 by 125 percent to get take into account factors such as the complexity, $2,000. We call this the “recognized” or amount of time needed and manner of billing. The effects of these policies will be refl ected in Step 2: We calculate the portion we pay. your Explanation of Benefi ts documents.
Your plan also says that you must pay “coinsurance.” This is your share of the Claims Payment for
“recognized” or “allowed” amount. For example, Non-Network Providers
your share may be 30 percent. In that case, If your plan provides coverage for services rendered by non-network providers, you should amount, which is $1,400. You pay your provider be aware that Aetna determines the allowable fee your 30 percent coinsurance, which is $600. for a non-network provider by referring to the Your provider may also ask you to pay the Original Medicare approved amount, which is $500 difference between the $2,500 bill and the maximum amount that Original Medicare the $2,000 “recognized” or “allowed” amount. allows a provider to accept. Charges by a non- In this case, your provider could bill you $1,100 network provider in excess of the Medicare approved amount will not be covered by Aetna, nor are they the responsibility of the member. You may be responsible for any charges Aetna determines are not covered under your plan, as well as any cost sharing outlined in your plan documents.
Technology Review
Medically Necessary
“Medically necessary” means that the service behavioral health procedures, pharmaceuticals or supply is provided by a physician or other and devices to determine which one should be health care provider exercising prudent clinical covered by our plans. And we even look at new uses for existing technologies to see if they have evaluating, diagnosing or treating an illness, potential. To review these innovations, we may: injury or disease or its symptoms, and that • Study published medical research and scientifi c evidence on the safety and effectiveness of • In accordance with generally accepted standards • Consider position statements and clinical • Clinically appropriate in accordance with generally accepted standards of medical practice government groups, including the federal in terms of type, frequency, extent, site and Agency for Health Care Research and Quality duration, and considered effective for the • Seek input from relevant specialists and experts • Not primarily for the convenience of you, • Determine whether the technologies are or for the physician or other health care You can fi nd out more on new tests and • Not more costly than an alternative service or treatments in our Clinical Policy Bulletins. sequence of services at least as likely to produce See Clinical Policy Bulletins below for more equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the illness, injury or disease.
For these purposes “generally accepted standards of medical practice” means standards that are based on credible scientifi c evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, or otherwise consistent with physician specialty society recommendations and the views of physicians practicing in relevant clinical areas and any other relevant factors.
Clinical Policy Bulletins
Utilization Review/Patient
Clinical Policy Bulletins (CPBs) describe Management
our policy determinations of whether certain services or supplies are medically necessary or program to assist in determining what health experimental or investigational, based on a care services are covered under the health plan review of currently available clinical information. and the extent of such coverage. The program Clinical determinations in connection with assists you in receiving appropriate health care individual coverage decisions are made on a case- and maximizing coverage for those health care by-case basis consistent with applicable policies.
services. You can avoid receiving an unexpected Aetna CPBs do not constitute medical advice. bill with a simple call to Member Services. You Treating providers are solely responsible for can fi nd out if your preventive care service, medical advice and for your treatment. You diagnostic test or other treatment is a covered benefi t — before you receive care — just by
coverage or condition with your treating calling the toll-free number on your ID card. provider. While Aetna CPBs are developed In certain cases, we review your request to be to assist in administering plan benefi ts, they sure the service or supply is consistent with do not constitute a description of plan benefi ts. established guidelines and is a covered benefi t Each benefi t plan defi nes which services are under your plan. We call this “utilization covered, which are excluded, and which are subject to dollar caps or other limits. You and We follow specifi c rules to help us make your your providers will need to consult the benefi t plan to determine if there are any exclusions • Aetna employees are not compensated based or other benefi t limitations applicable to this • We do not encourage denials of coverage. In CPBs are regularly updated and are therefore fact, our utilization review staff is trained to subject to change. You can fi nd them online at focus on the risks of members not adequately www.aetna.com under “Members” and then
“Health Coverage Information.” If you do not Where such use is appropriate, our Utilization have Internet access, please contact Member Review/Patient Management staff uses nationally Services at the toll-free number on your ID recognized guidelines and resources, such card for information about specifi c Clinical as The Milliman Care Guidelines® to guide the precertifi cation, concurrent review and retrospective review processes. To the extent certain Utilization Review/Patient Management functions are delegated to IDSs, IPAs or other provider groups (“Delegates”), such Delegates utilize criteria that they deem appropriate. Utilization Review/Patient Management policies may be modifi ed to comply with applicable state law.
Only medical professionals make decisions Retrospective Record Review
denying coverage for services for reasons of Retrospective review is a review conducted medical necessity. Coverage denial letters for after the patient has been discharged from the such decisions delineate any unmet criteria, hospital or facility. The purpose of retrospective standards and guidelines, and inform the review is to retrospectively analyze potential provider and you of the appeal process. For quality and utilization issues, initiate appropriate follow-up action based on quality or utilization management, you may request a free copy of issues, and review all appeals of inpatient the criteria we use to make specifi c coverage concurrent review decisions for coverage of health decisions by contacting Member Services. care services. Our effort to manage the services You may also visit www.aetna.com/about/
provided to you includes the retrospective review cov_det_policies.html to fi nd our Clinical
of claims submitted for payment, and of medical Policy Bulletins and some utilization review records submitted for potential quality and policies. Doctors or health care professionals who have questions about your coverage can write or call our Patient Management Organization Determinations,
department. The address and phone number Coverage Determinations, Grievances
and Appeals
Concurrent Review
As a member of Aetna Medicare Plan (HMO) (PPO), you have the right to request an Concurrent review is a review conducted while organization determination, which includes the a patient is confi ned on an inpatient basis. right to fi le an appeal if we deny coverage for an The concurrent review process assesses the item or service, and the right to fi le a grievance. necessity for continued stay, level of care, and You have the right to request an organization quality of care for members receiving inpatient determination if you want us to provide or pay services. All inpatient services extending beyond for an item or service that you believe should be the initial certifi cation period will require covered. If we deny coverage for your requested item or service, you have the right to appeal and Discharge Planning
ask us to review our decision. You may ask us for an expedited (fast) coverage determination or Discharge planning may be initiated at any appeal if you believe that waiting for a decision stage of the patient management process and could seriously put your life or health at risk, or begins immediately upon identifi cation of affect your ability to regain maximum function. post-discharge needs during precertifi cation If your doctor makes or supports the expedited or concurrent review. The discharge plan may request, we must expedite our decision. Finally, include initiation of a variety of services/benefi ts you have the right to fi le a grievance with us if to be utilized by you upon discharge from an you have any type of problem with us or one of our network providers that does not involve coverage for an item or service. If your problem involves quality of care, you also have the right to fi le a grievance with the Quality Improvement Organization (QIO) for your state. For detailed information about Aetna’s grievance, Member Rights & Responsibilities
You have the right to receive a copy of our processes, forms and our contact information, Member Rights and Responsibilities Statement. please refer to our Aetna Medicare website: This information is available to you at www.
http://www.aetnamedicare.com/plan_choices/ aetna.com/about/MemberRights. You can
also obtain a print copy by contacting Member As a member of Aetna Medicare Plan (HMO) Services at the number on your ID card.
(PPO), you have the right to request a coverage determination, which includes the right to Member Services
request an exception, the right to fi le an appeal To fi le a complaint or an appeal, for additional if we deny coverage for a prescription drug, and information regarding copayments and other the right to fi le a grievance. You have the right to charges, information regarding benefi ts, to request a coverage determination if you want us obtain copies of plan documents, information to cover a Part D drug that you believe should regarding how to fi le a claim or for any other be covered. An exception is a type of coverage question, you can contact Member Services at determination. You may ask us for an exception the toll-free number on your ID card, or email if you believe you need a drug that is not on our us from your secure Aetna Navigator member list of covered drugs or believe you should get a website at www.aetna.com. Click on “Contact
non-preferred drug at a lower out-of-pocket cost.
You can also ask for an exception to cost Interpreter/Hearing Impaired
utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, When you require assistance from an Aetna you should contact us before you try to fi ll your representative, call us during regular business prescription at a pharmacy. Your doctor must hours at the number on your ID card. Our provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to fi le a grievance if you have any type of problem • Advise you on how to fi le complaints and with us or one of our network pharmacies that does not involve coverage for a prescription drug. • Connect you to behavioral health services If your problem involves quality of care, you also have the right to fi le a grievance with the Quality Improvement Organization (QIO) for your state.
For detailed information about Aetna’s grievance, coverage determination, and appeals processes, forms and our contact information, please refer Multilingual hotline — 1-888-982-3862
to our Aetna Medicare website: http://www.
(140 languages are available. You must ask for aetnamedicare.com/plan_choices/rx_exceptions_ TTY/TDD 1-888-760-4748
(hearing impaired only)
Quality Management Programs
When necessary or appropriate for your care We have a comprehensive quality measurement or treatment, the operation of our health plans, and improvement strategy, and do not view it as or other related activities, we use personal an isolated, departmental function. Rather, we information internally, share it with our integrate quality management and metrics into affi liates, and disclose it to health care providers all that we do. For details on our program, goals (doctors, dentists, pharmacies, hospitals and and our progress on meeting those goals, go to other caregivers), payors (health care provider www.aetna.com/members/ health_coverage/
organizations, employers who sponsor self- quality/quality.html. If you do not have
funded health plans or who share responsibility Internet access and would like a hard copy of for the payment of benefi ts, and others who the information referenced here, please contact may be fi nancially responsible for payment for Member Services at the toll-free number on your the services or benefi ts you receive under your plan), other insurers, third party administrators, vendors, consultants, government authorities, Privacy Notice
and their respective agents. These parties Aetna considers personal information to be are required to keep personal information confi dential and has policies and procedures confi dential as provided by applicable law. in place to protect it against unlawful use and Participating network providers are also required disclosure. By “personal information,” we mean to give you access to your medical records information that relates to your physical or within a reasonable amount of time after you mental health or condition, the provision of health care to you, or payment for the provision Some of the ways in which personal information of health care to you. Personal information does is used include claims payment; utilization not include publicly available information or review and management; medical necessity information that is available or reported in a reviews; coordination of care and benefi ts; summarized or aggregate fashion but does not preventive health, early detection, and disease and case management; quality assessment and improvement activities; auditing and anti-fraud activities; performance measurement and outcomes assessment; health claims analysis and reporting; health services research; data and information systems management; compliance with legal and regulatory requirements; formulary management; litigation proceedings; transfer of policies or contracts to and from other insurers, HMOs and third party administrators; underwriting activities; and due diligence activities in connection with the purchase or sale of some or all of our business. We consider these activities key for the operation of our health plans. To the extent permitted by law, we use and disclose personal information as provided above without your consent.
However, we recognize that you may not want Use of Race, Ethnicity and
to receive unsolicited marketing materials Language Data
unrelated to your health benefi ts. We do not Aetna members have the option to provide us disclose personal information for these marketing with race/ ethnicity and preferred language purposes unless you consent. We also have information. This information is voluntary and policies addressing circumstances in which you confi dential. We collect this information to identify research, develop, implement and/or To request a printed copy of our Notice of enhance initiatives to improve health care access, Privacy Practices, which describes in greater detail delivery and outcomes for diverse members, our practices concerning use and disclosure of and otherwise improve services to our members. We will maintain administrative, technical and physical safeguards to protect information concerning member race, ethnicity and language preference from inappropriate access, use or You can also visit www.aetna.com and link
disclosure. This data will be collected, used or directly to the Notice of Privacy Practices by disclosed only in accordance with Aetna policies selecting the “Privacy Notices” link at the bottom and applicable state and federal requirements. It is not used to determine eligibility, rating or claim payment.
Non-discrimination statement
Aetna does not discriminate in providing access www.aetna.com. If you do not have Internet
to health care services on the basis of race, access and would like a hard copy of the disability, religion, sex, sexual orientation, health, information referenced here, please contact ethnicity, creed, age or national origin. We are Member Services at the toll-free number on required to comply with Title VI of the Civil Rights Act of 1964, the Age Discrimination Act of 1975, the Americans with Disabilities Act, other laws applicable to recipients of federal funds, and all other applicable laws and rules.
Health Insurance Portability and
Accountability Act
The following information is provided to inform you of certain
provisions contained in the Group Health Plan, and related procedures
that may be utilized by you in accordance with federal law.
Special Enrollment Rights
As a terminated member, you can request a If you are declining enrollment for yourself or certifi cate for up to 24 months following the date your dependents (including your spouse) because of your termination. As an active member, you of other health insurance or group health plan can request a certifi cate at any time. To request coverage, you may be able to enroll yourself a Certifi cate of Prior Health Coverage, please and your dependents in this plan if you or your contact Member Services at the telephone number dependents lose eligibility for that other coverage (or if the employer stops contributing to your Notice Regarding Women’s Health
or your dependents’ other coverage). However, you must request enrollment within 31 days and Cancer Rights Act
after your or your dependents’ other coverage Under this health plan, coverage will be provided ends (or after the employer stops contributing to a person who is receiving benefi ts for a to the other coverage). In addition, if you have medically necessary mastectomy and who elects a new dependent as a result of marriage, birth, breast reconstruction after the mastectomy for: adoption or placement for adoption, you may (1) reconstruction of the breast on which a be able to enroll yourself and your dependents. However, you must request enrollment within 31 (2) surgery and reconstruction of the other breast days after marriage, birth, adoption or placement for adoption. To request special enrollment or obtain more information, contact your benefi ts (4) treatment of physical complications of all stages of mastectomy, including lymph edemas.
Request for Certifi cate of
This coverage will be provided in consultation with the attending physician and the patient, and Creditable Coverage
will be subject to the same annual deductibles If you are a member of an insured plan sponsor and coinsurance provisions that apply for the or a member of a self-insured plan sponsor who have contracted with us to provide Certifi cates If you have any questions about our coverage of Prior Health Coverage, you have the option of mastectomies and reconstructive surgery, please contact the Member Services number on This applies to you if you are a terminated member, or are a member who is currently active but would like a certifi cate to verify your status. If you need this material translated into another language, please call Member Services at
1-888-982-3862. Si usted necesita este documento en otro idioma, por favor llame a Servicios
al Miembro al 1-888-982-3862.
Health insurance plans are offered by Aetna Health Inc., Aetna Health of California Inc. and/or Aetna Life Insurance Company. Coverage is provided through a Medicare Advantage organization or a Medicare Prescription Drug Plan Sponsor with a Medicare contract. Benefits, formulary, pharmacy network, premium, and/or copayments/coinsurance may change on January 1 of each year. Please contact Aetna Medicare for details.
This material is for informational purposes only. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional.

Source: http://www.aetnafamilyplan.biz/data/disclosures/18_28_310_1_MAPD_disclosure.pdf