Important Disclosure Information*
Aetna Open Choice® PPO (Aetna Choice® Plan PPO)
The applicability and amount of each copay and deductible
listed above will be determined by your plan sponsor and
described in your plan documents.
Plan of Benefits
Your plan of benefits will be determined by your plan
sponsor and underwritten or administered by Aetna Life
Insurance Company,151 Farmington Avenue, Hartford, CT
06156. The benefits and main points of the Service
Agreement or Group Policy of your plan of benefits will be
set forth in the Booklet-certificate or Booklet, which will be
provided to you at a later date.
Transplants and Other Complex
Conditions
Our National Medical Excellence Program® and other
specialty programs help eligible members access covered
treatment for transplants and certain other complex
medical conditions at participating facilities experienced in
performing these services. Depending on the terms of your
plan of benefits, members may be limited to only those
facilities participating in these programs when needing a
transplant or other complex condition covered.
Covered services include most types of treatment provided
by primary care physicians, specialists and hospitals.
However, the health plan excludes or limits coverage for
some services, including, but not limited to, cosmetic
surgery and experimental procedures. In addition, in order
to be covered, all services, including the location (type of
facility), duration and costs of services must be necessary
as defined in the plan documents and as determined by
Aetna. The information that follows provides general
information regarding Aetna plans. Members should
consult their plan documents for a complete description of
what health care services are covered and any applicable
exclusions and limitations.
Emergency Care
If you need emergency care, you are covered 24 hours a
day, 7 days a week, anywhere in the world. An emergency
medical condition is one manifesting itself by acute
symptoms of sufficient severity such that a prudent
layperson, who possesses average knowledge of health
and medicine, could reasonably expect the absence of
immediate medical attention to result in serious jeopardy
to the person's health, or with respect to a pregnant
woman, the health of the woman and her unborn child.
Member Copays and Deductibles
Your plan of benefits may contain some or all of the
following features:
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Whether you are in or out of an Aetna service area, we
simply ask that you follow the guidelines below when you
believe you need emergency care.
Copayments - These are fees that you must pay for
some covered medical expenses.
Calendar Year Deductible - The amount of covered
medical expenses you pay each calendar year before
benefits are paid. There is a calendar year deductible
that applies to each person.
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Inpatient Hospital Deductible - This is the amount of
covered inpatient hospital expenses you pay for each
hospital confinement.
Emergency Room Deductible - 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.
*Specific state variations and plan documents supersede general disclosures
contained within, as applicable. Be certain to review the state-specific
language in the State Variations section, which follows. State mandates do
not apply to self-funded plans. If you are unsure if your plan is self-funded,
please confer with your benefits administrator.
** Aetna is the brand name used for products and services provided by one
or more of the Aetna group of subsidiary companies.
www.aetna.com
03.28.301.1-OC (7/05)
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Call the local emergency hotline (ex. 911) or go to the
nearest emergency facility. If a delay would not be
detrimental to your health, call your PCP. Notify your
PCP as soon as possible after receiving treatment.
If you are admitted to an inpatient facility, you or a
family member or friend on your behalf should notify
your PCP or Aetna within 48 hours of the start of
confinement as a full-time inpatient (72 hours if the
confinement starts on a Friday or Saturday) or as soon
as reasonably possible.
Prescription Drugs
copayment if you obtain the brand-name drug.
Nonprescription drugs and drugs in the Limitations and
Exclusions section of the plan documents (received and/or
available upon enrollment) are not covered, and medical
exceptions are not available for them.
If your plan covers outpatient prescription drugs, your plan
may include a preferred drug list (also known as a "drug
formulary"). The preferred drug list includes a list of
prescription drugs that, depending on your prescription
drug benefits plan, are covered on a preferred basis. Many
drugs, including many of those listed on the preferred drug
list, are subject to rebate arrangements between Aetna and
the manufacturer of the drugs. Such rebates are not
reflected in and do not reduce the amount a member pays
for a prescription drug. In addition, in circumstances where
your prescription plan utilizes copayments or coinsurance
calculated on a percentage basis or a deductible, your costs
may be higher for a preferred drug than they would be for
a nonpreferred drug. For information regarding how
medications are reviewed and selected for the preferred
drug list, please refer to Aetna's website at
www.aetna.com or the Aetna 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.
Additional information can be obtained by calling Member
Services at the toll-free number listed on your member ID
card. The medications listed on the preferred drug list are
subject to change in accordance with applicable state law.
Depending on the plan selected, new prescription drugs
not yet reviewed for possible addition to the preferred
drug list are either available at the highest copay under
plans with an "open" formulary, or excluded from
coverage unless a medical exception is obtained under
plans that use a "closed" formulary. These new drugs may
also be subject to precertification or step-therapy.
Members should consult with their treating physicians
regarding questions about specific medications. Refer to
your plan documents or contact Member Services for
information regarding terms, conditions and limitations of
coverage. If you use the mail order prescription program of
Aetna Rx Home Delivery, LLC, you will be acquiring these
prescriptions through an affiliate of Aetna. Aetna's
negotiated charge with Aetna Rx Home Delivery® may be
higher than Aetna Rx Home Delivery's cost of purchasing
drugs and providing mail-order pharmacy services. For
these purposes, Aetna Rx Home Delivery's cost of
purchasing drugs takes into account discounts, credits and
other amounts that it may receive from wholesalers,
manufacturers, suppliers and distributors.
Your prescription drug benefit is generally not limited to
drugs listed on the preferred drug list. Medications that are
not listed on the preferred drug list (nonpreferred or
nonformulary drugs) may be covered subject to the limits
and exclusions set forth in your plan documents. Covered
nonformulary prescription drugs may be subject to higher
copayments or coinsurance under some benefit plans.
Some prescription drug benefit plans may exclude from
coverage certain nonformulary drugs that are not listed on
the preferred drug list. If it is medically necessary for
members enrolled in these benefit plans to use such drugs,
their physicians (or pharmacist in the case of antibiotics
and analgesics) may contact Aetna to request coverage as
a medical exception. Check your plan documents for
details.
If you use the Aetna Specialty Pharmacy specialty drug
program, you will be acquiring these prescriptions through
Aetna Specialty Pharmacy, LLC, which is jointly owned by
Aetna and Priority Healthcare, Inc. Aetna's negotiated
charge with Aetna Specialty Pharmacy may be higher than
Aetna Specialty Pharmacy's cost of purchasing drugs and
providing specialty pharmacy services. For these purposes,
Aetna Specialty Pharmacy's cost of purchasing drugs takes
into account discounts, credits and other amounts that it
may receive from wholesalers, manufacturers, suppliers
and distributors.
Behavioral Health Network
If your plan through Aetna includes coverage for
behavioral health care services, certain of these services are
managed by an independently contracted behavioral
health care organization. For example, the behavioral
health care organization is responsible for, in part, making
initial coverage determinations and coordinating referrals
to members of the behavioral health care organization's
provider network.
In addition, certain drugs may require precertification or
step-therapy before they will be covered under some
prescription drug benefit plans. Step-therapy is a different
form of precertification which requires a trial of one or
more "prerequisite therapy" medications before a "step
therapy" medication will be covered. If it is medically
necessary for a member to use a medication subject to
these requirements, the member's physician can request
coverage of such drug as a medical exception. In addition,
some benefit plans include a mandatory generic drug costsharing requirement. In these plans, you may be required
to pay the difference in cost between a covered brandname drug and its generic equivalent in addition to your
If your plan includes behavioral health care services, you
can receive information regarding the appropriate way to
access behavioral health care services that are covered
under your specific plan by calling the Behavioral Health
Vendor toll-free number on your ID card or, if there is not a
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specific number listed, call the Member Services number
on your ID card for the appropriate information. As with
other coverage determinations, you may appeal adverse
behavioral health care coverage determinations in
accordance with the provisions of your health plan and/or
applicable state law.
Aetna's CPBs do not constitute medical advice. Treating
providers are solely responsible for medical advice and
treatment of members. Members should discuss any CPB
related to their coverage or condition with their treating
provider.
While Aetna's CPBs are developed to assist in
administering plan benefits, they do not constitute a
description of plan benefits. Each benefit plan defines
which services are covered, which are excluded, and which
are subject to dollar caps or other limits. Members and
their providers will need to consult the member's benefit
plan to determine if there are any exclusions or other
benefit limitations applicable to this service or supply.
How Aetna Compensates Your Physician
and Other Providers
All the physicians in the directory are independent
practicing physicians that are neither employed nor
exclusively contracted with Aetna. Individual physicians are
in the network by either directly contracting with Aetna
and/or affiliating with a group or organization that
contracts with us.
CPBs are regularly updated and are therefore subject to
change. Aetna's CPBs are available online at
www.aetna.com.
Participating physicians, hospitals and other providers in
our network are compensated in various ways for the
services covered under your plan.
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Precertification is the process of collecting information prior
to inpatient admissions and performance of selected
ambulatory procedures and services. The process permits
advance determination of the medical necessity and
appropriateness of the procedures and services from a
coverage perspective, and communication with the
physician and/or member. It also allows Aetna to
coordinate the patient's transition from the inpatient
setting to the next level of care (discharge planning), or to
register patients for specialized programs like disease
management, case management, or our prenatal program.
In some instances, precertification is used to inform
physicians, members and other health care providers about
cost-effective programs and alternative therapies and
treatments.
Per individual service or case (fee for service at
contracted rates).
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Precertification and Necessary Services
Per hospital day (per diem contracted rates).
Non-participating providers providing covered services are
reimbursed on a fee-for-service basis.
You are encouraged to ask your physicians and other
providers how they are compensated for their services.
Claims Payment for Non-participating
Providers and Use of Claims Software
If your plan provides coverage for services rendered by
nonparticipating providers, you should be aware that
Aetna determines the usual, customary and reasonable fee
for a provider by referring to commercially available data
reflecting the customary amount paid to most providers for
a given service in that geographic area. If such data is not
commercially available, our determination may be based
upon our own data or other sources.
Certain health care services, such as hospitalization or
outpatient surgery, require precertification with Aetna to
obtain coverage for those services. When a member is to
obtain services requiring precertification through a
preferred provider, this provider should precertify those
services prior to treatment.
Aetna may also use computer software (including
ClaimCheck) and other tools to take into account factors
such as the complexity, amount of time needed and
manner of billing. You may be responsible for any charges
Aetna determines are not covered under your plan.
If your plan covers out-of-network benefits and you may
self-refer for covered services, it is your responsibility to
contact Aetna to precertify those services which require
precertification.
You must obtain precertification for certain types of care
rendered by non-preferred providers to avoid a reduction
in benefits paid for that care.
Clinical Policy Bulletins ("CPBs")
Aetna's CPBs describe Aetna's policy determinations of
whether certain services or supplies are medically
necessary, based upon a review of currently available
clinical information. Clinical determinations in connection
with individual coverage decisions are made on a case-by
case basis consistent with applicable policies.
Refer to your plan documents for specific information.
Only medically necessary services are covered. A service or
supply furnished by a particular provider is medically
necessary if Aetna determines that it is appropriate for the
diagnosis, the care or the treatment of the disease or injury
involved.
www.aetna.com
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Medically Necessary
Only medical directors make decisions denying
coverage for services for reasons of medical
necessity. Coverage denial letters for such decisions
delineate any unmet criteria, standards and guidelines, and
inform the provider and member of the appeal process.
"Medically necessary" means that the service or supply is
provided by a physician or other health care provider
exercising prudent clinical judgment for the purpose of
preventing, evaluating, diagnosing or treating an illness,
injury or disease or its symptoms, and that provision of the
service or supply is:
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Considered effective in accordance with generally
accepted standards of medical practice for the
illness, injury or disease; and
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The concurrent review process assesses the necessity for
continued stay, level of care, and quality of care for
members receiving inpatient services. All inpatient services
extending beyond the initial certification period will require
concurrent review.
Clinically appropriate in accordance with generally
accepted standards of medical practice in term of
type frequency, extent, site and duration,
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Concurrent Review
Not primarily for the convenience of the Member, or for
the physician or other health care provider; and
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Discharge Planning
Discharge planning may be initiated at any stage of the
patient management process and begins immediately upon
identification of post-discharge needs during precertification
or concurrent review. The discharge plan may include
initiation of a variety of services/benefits to be utilized by
the member upon discharge from an inpatient stay.
Not more costly than an alternative service or sequence
of services at least as likely to produce equivalent
therapeutic or diagnostic results as to the diagnosis or
treatment of the illness, injury or disease.
"Generally accepted standards of medical practice"
means standards that are based on credible scientific
evidence published in peer-reviewed medical literature
generally recognized by the relevant medical community. In
the absence of such credible scientific evidence,
[Plan/HMO/Company]'s determinations of whether a
service or supply meets "generally accepted standards of
medical practice" shall be consistent with physician
specialty society recommendations and otherwise shall be
based on the views of physicians practicing in relevant
clinical areas and any other relevant factors.
Retrospective Record Review
The purpose of retrospective review is to retrospectively
analyze potential quality and utilization issues, initiate
appropriate follow-up action based on quality or utilization
issues, and review all appeals of inpatient concurrent
review decisions for coverage and payment of health care
services. Aetna's effort to manage the services provided to
members includes the retrospective review of claims
submitted for payment and of medical records submitted
for potential quality and utilization concerns.
Utilization Review/Patient Management
Complaints, Appeals and External
Review*
Aetna has developed a patient management program to
assist in determining what health care services are covered
under the health plan and the extent of such coverage.
Filing a Complaint or Appeal
Aetna is committed to addressing members' coverage
issues, complaints and problems. If you have a coverage
issue or other problem, call Member Services at the tollfree number on your ID card. You can also contact
Member Services through the Internet at
www.aetna.com. If Member Services is unable to resolve
your issue to your satisfaction, it will be forwarded to the
appropriate department for handling.
The program assists members in receiving appropriate
healthcare and maximizing coverage for those healthcare
services.
Where such use is appropriate, our utilization
review/patient management staff uses nationally
recognized guidelines and resources, such as The Milliman
Care Guidelines™ to guide the precertification, concurrent
review and retrospective review processes. To the extent
certain utilization review/patient management functions
are delegated to integrated delivery systems, independent
practice associations or other provider groups
("Delegates"), such Delegates utilize criteria that they
deem appropriate. Utilization review/patient management
polices may be modified to comply with applicable state
law.
If you are dissatisfied with the outcome of your initial
contact, you may file an appeal. If you are not satisfied
after filing a formal appeal, you may request a second level
appeal of the decision.
Your appeal will be decided in accordance with the
procedures applicable to your plan and applicable state
law. Refer to your plan documents for further details
regarding your plan's appeal procedure.
*This Complaint Appeal and External Review process may not apply if your plan is self-funded. Contact your Benefits Administrator if you have any questions.
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External Review
Aetna established an external review process to give
eligible members the opportunity of requesting an
objective and timely independent review of certain
coverage denials. Once the applicable appeal process has
been exhausted, eligible members may request an external
review of the decision if the coverage denial, for which the
member would be financially responsible, involves more
than $500, and is based on lack of medical necessity or on
the experimental or investigational nature of the proposed
service or treatment. Standards may vary by state, if a
state-mandated external review process exists and applies
to your plan.
When necessary or appropriate for your care or treatment,
the operation of our health plans, or other related
activities, we use personal information internally, share it
with our affiliates, and disclose it to health care providers
(doctors, dentists, pharmacies, hospitals and other
caregivers), payors (health care provider organizations,
employers who sponsor self-funded health plans or who
share responsibility for the payment of benefits, and others
who may be financially responsible for payment for the
services or benefits you receive under your plan), other
insurers, third-party administrators, vendors, consultants,
government authorities, and their respective agents. These
parties are required to keep personal information
confidential as provided by applicable law. Participating
network providers are also required to give you access to
your medical records within a reasonable amount of time
after you make a request.
An independent review organization (IRO) will assign the
case to a physician reviewer with appropriate expertise in
the area in question. After all necessary information is
submitted, an external review generally will be decided
within 30 calendar days of the request. Expedited reviews
are available when a member's physician certifies that a
delay in service would jeopardize the member's health.
Once the review is complete, the plan will abide by the
decision of the external reviewer. The cost for the review
will be borne by Aetna (except where state law requires
members to pay a filing fee as part of the state mandated
program).
Some of the ways in which personal information is used
include claims payment; utilization review and
management; medical necessity reviews; coordination of
care and benefits; preventive health, early detection, and
disease and case management; quality assessment and
improvement activities; auditing and antifraud 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 member consent.
However, we recognize that many members do not want
to receive unsolicited marketing materials unrelated to
their health benefits. We do not disclose personal
information for these marketing purposes unless the
member consents. We also have policies addressing
circumstances in which members are unable to give
consent.
Certain states mandate external review of additional
benefit or service issues; some may require a filing fee.
In addition, certain states mandate the use of their own
external review process for medical necessity and
experimental/ investigational coverage decisions. These
state mandates may not apply to self-funded plans. For
further details regarding your plan's appeal process and
the availability of an external review process, call the
Member Services toll-free number on your ID card or visit
our website at www.aetna.com where you may obtain
an external review request form. You also may call your
state insurance or health department or consult their
website for additional information regarding statemandated external review procedures.
Confidentiality and Privacy Notices
Aetna considers personal information to be confidential
and has policies and procedures in place to protect it
against unlawful use and disclosure. By "personal
information," we mean information that relates to a
member's physical or mental health or condition, the
provision of health care to the member, or payment for the
provision of health care to the member. Personal
information does not include publicly available information
or information that is available or reported in a
summarized or aggregate fashion but does not identify the
member.
To obtain a hard copy of our Notice of Privacy Practices,
which describes in greater detail our practices concerning
use and disclosure of personal information, please write to
Aetna's Legal Support Services Department at 151
Farmington Avenue, W121, Hartford, CT 06156. You can
also visit our Internet site at www.aetna.com. You can
link directly to the Notice of Privacy Practices by selecting
the "Privacy Notices" link at the bottom of the page.
www.aetna.com
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State Variations*
Georgia
Hawaii
Members can call 1-800-223-6857 (toll-free) to confirm
that the preferred provider in question is in the network
and/or accepting new patients.
Informed Consent
Members have the right to be fully informed prior to
making any decision about any treatment, benefit, or
nontreatment.
Members have direct access to the participating primary
Ob/Gyn provider of their choice and do not need a referral
from their PCP for a routine well-woman exam, including a
Pap smear when appropriate and an unlimited number of
visits for gynecologic problems and follow-up care.
Your provider will:
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A summary of any agreement or contract between Aetna
and any health care provider will be made available upon
request by calling the Member Services telephone number
on your ID card. The summary will not include financial
agreements as to actual rates, reimbursements, charges, or
fees negotiated by Aetna and the provider. The summary
will include a category or type of compensation paid by
Aetna to each class of health care provider under contract
with Aetna.
ensure that persons with disabilities have an effective
means of communication with the provider and other
members of the managed care plan; and
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Members also have direct access to the participating
dermatologist provider of their choice and do not need a
referral from their primary care physicians to access
dermatologic benefits covered under their health plan.
discuss all treatment options, including the option of no
treatment at all;
discuss all risks, benefits, and consequences of
treatment and non-treatment.
Your provider will also discuss with you and your
immediate family both living wills and durable powers of
attorney in relation to medical treatment.
Insurance Division Telephone Number:
You may contact the Hawaii Insurance Division and the
Office of Consumer Complaints at 1-(808) 586-2790.
Illinois
While every provider listed in the provider directory
contracts with Aetna to provide primary care services, not
every provider listed will be accepting new patients.
Although Aetna has identified those providers who were
not accepting patients as known to Aetna at the time the
Provider Directory was created, the status of the physician's
practice may have changed. For the most current
information regarding the status of any physician's
practice, please contact either the selected physician or call
Member Services at the toll-free number on your ID card.
Consumer Choice Option
The Consumer Choice Option is available for Georgia
residents enrolled in certain Aetna managed care plans.
Under this benefit option, with certain restrictions required
by law and an additional monthly premium cost, members
of certain Aetna managed care plans may nominate an
out-of-network provider to provide covered services for
themselves and their covered family members. Your
benefits and any applicable copayments will be the same
as for in-network providers. The out-of-network provider
must agree to accept the Aetna compensation, to adhere
to the plan's quality assurance requirements, and to meet
all other reasonable criteria required by the plan of its innetwork participating providers. It is possible the provider
you nominate will not agree to participate.
Illinois law requires health plans to provide the following
information annually to enrollees and to prospective
enrollees upon request: a complete list of participating
health care providers in the health care plan's service area
and a description of the following terms of coverage:
1. The service area;
This option is available for an increased premium in
addition to the premium you would otherwise pay. Your
increased premium responsibility will vary depending on
whether you have a single plan or family coverage, and on
the type of insurance, riders, and coverage. Exact pricing
and any additional information can be obtained by calling
1-800-433-6917. Please have your Aetna member ID card
available when you call.
2. The covered benefits and services with all exclusions,
exceptions and limitations;
3. The pre-certification and other utilization review
procedures and requirements;
4. A description of the process for the selection of a PCP,
any limitation on access to specialists, and the plan's
standing referral policy;
5. The emergency coverage and benefits, including any
restrictions on emergency care services;
*In some states, Aetna provides additional consumer disclosures in documents also posted on our website at www.aetna.com.
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6. The out-of-area coverage and benefits, if any;
Kentucky
7. The enrollee's financial responsibility for copayments,
deductibles, premiums, and any other out-of-pocket
expenses;
Any provider who meets our enrollment criteria and who is
willing to meet the terms and conditions for participation
has a right to become a participating provider in our
network.
8. The provisions for continuity of treatment in the event
a health care provider's participation terminates during
the course of an enrollee's treatment by the provider;
Emergency Medical Condition Definition
A medical condition manifesting itself by acute symptoms
of sufficient severity, including severe pain, that a prudent
layperson would reasonably have cause to believe
constitutes a condition that the absence of immediate
medical attention could reasonably be expected to result
in: placing the health of the individual or, with respect to a
pregnant woman, the health of the woman or her unborn
child, in serious jeopardy; serious impairment to bodily
functions; or serious dysfunction of any bodily organ or
part; or with respect to a pregnant woman who is having
contractions, a situation in which there is inadequate time
to effect a safe transfer to another hospital before delivery;
or a situation in which transfer may pose a threat to the
health or safety of the woman or the unborn child.
9. The appeals process, forms, and time frames for
health care services appeals, complaints, and external
independent reviews, administrative complaints, and
utilization review complaints, including a phone
number to call to receive more information from the
health care plan concerning the appeals process; and
10. A statement of all basic health care services and all
specific benefits and services to be provided to
enrollees by a State law or administrative rule.
Additionally, upon written request, the health plan will
provide enrollees with a description of the financial
relationship between the health plan and any health care
provider, including, if requested, the percentage of
copayments, deductibles, and total premiums spent on
health care related expenses and the percentage of
copayments, deductibles and total premiums spent on
other expenses, including administrative expenses.
Louisiana
Aetna will not in any way use the results of genetic testing
to discriminate against applicants or enrollees.
Kansas
Maryland
Kansas law permits you to have the following information
upon request:
Behavioral Health Care Expense Form
To obtain a copy of the Behavioral Health Care Expense
Form, please call the number located on the back of your
ID card.
1. A complete description of the health care services,
items and other benefits to which the insured is entitled
in the particular health plan which is covering or being
offered to such person;
Michigan
2. A description of any limitations, exceptions or
exclusions to coverage in the health benefit plan,
including prior authorization policies, restricted drug
formularies or other provisions which restrict access to
covered services or items by the insured;
Contact the Michigan Office of Financial and Insurance
Services at 1-517-373-0220 to verify participating
providers’ license or to access information on formal
complaints and disciplinary actions filed or taken against
participating providers.
3. A listing of the plan's participating providers, their
business addresses and telephone numbers, their
availability, and any limitation on an insured's choice of
provider;
Intractable Pain
Aetna Health provides benefits for the evaluation and
treatment of intractable pain when it is determined to be
medically necessary and otherwise eligible by Aetna
Health. Intractable pain means “a pain state in which the
cause of the pain cannot be removed or otherwise treated
and which, in the generally accepted practice of allopathic
or osteopathic medicine, no relief of the cause of the pain
or cure of the cause of the pain is possible or none has
been found after reasonable efforts, including, but not
limited to, evaluation by the attending physician and by 1
or more other physicians specializing in the treatment of
the area, system, or organ of the body perceived as the
source of the pain.”
4. Notification in advance of any changes in the health
benefit plan which either reduces the coverage or
benefits or increases the cost to such person; and
5. A description of the grievance and appeal procedures
available under the health benefit plan and an insured's
rights regarding termination, disenrollment, nonrenewal
or cancellation of coverage.
www.aetna.com
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To obtain this and further information on the health plan
you may call Member Services at 1-800-208-8755 or refer
to your plan documents.
Texas
Please refer to the plan design overview and summary of
riders contained in your pre-enrollment packet for a brief
description of the services and benefits covered under your
particular plan, as well as those services and benefits that
are excluded. After enrollment, you can refer to your plan
documents for a more complete description of your
covered services and benefits and the exclusions under
your plan. For information on whether a specific service is
covered or excluded, please contact Member Services at
the tollfree number on your ID card.
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Health Insurance Portability and
Accountability Act Member Notice*
The following information is provided to inform the member of certain provisions
contained in the Group Health Plan, and related procedures that may be utilized by the
member in accordance with Federal law.
If you had no prior creditable coverage within the 90
days prior to your enrollment date (either because you had
no prior coverage or because there was more than a 90
day gap from the date your prior coverage terminated to
your enrollment date), we will apply your plan's preexisting conditions exclusion (to a maximum period of 12
months).
Pre-existing Conditions Exclusion
Provision (only for plans containing
such provision)
This is to advise you that a pre-existing conditions exclusion
period may apply to you, if a pre-existing conditions
exclusion provision is included in the Group Plan that you
are or become covered under. If your plan contains preexisting conditions exclusion, such exclusion may be
waived for you if you have prior Creditable Coverage.
Providing Proof of Creditable Coverage
Generally, you will have received a certification of prior
health coverage from your prior medical plan as proof of
your prior coverage. You should retain that certification
until you submit a medical claim. When a claim for
treatment of a potential pre-existing condition is received,
the claim office will request from you that certification of
prior health coverage, which will be used to determine if
you have creditable coverage at that time.
Note: If a state law mandates a gap period greater than
90 days, that longer gap period will be used to determine
creditable coverage.
If you have any questions regarding the determination of
whether or not pre-existing conditions exclusion applies to
you, please call the Member Services telephone number on
your ID card.
You may request a certification of prior health
coverage from your prior carrier(s) with whom you had
coverage within the past two years. Our Service Center can
assist you with this and can provide you with the type of
information that you will need to request from your prior
carrier. The Service Center may also request information
from you regarding any pre-existing condition for which
you may have been treated in the past, and other
information that will allow them to determine if you have
creditable coverage.
Creditable Coverage
Creditable coverage includes coverage under a group
health plan (including a governmental or church plan),
health insurance coverage (either group or individual
insurance), Medicare, Medicaid, military-sponsored health
care (TRICARE) a program of the Indian Health Service, a
State health benefit risk pool, the FEHBP, a public health
plan as defined in the regulations, and any health benefit
plan under section 5(c) of the Peace Corps Act. Not
included as creditable coverage is any coverage that is
exempt from the law (e.g., dental only coverage or dental
coverage that is provided in a separate plan or even if in
the same plan as medical, is separately elected and results
in additional premium).
Special Enrollment Periods
Due to Loss of Coverage
If you are eligible for coverage under your employer's
medical plan but do/did not enroll in that medical plan
because you had other medical coverage, and you lose
that other medical coverage, you will be allowed to enroll
in the current medical plan during special enrollment
periods after your initial eligibility period, if certain
conditions are met. These special enrollment rules apply to
employees and/or dependents who are eligible, but not
enrolled for coverage, under the terms of the plan.
If you had prior creditable coverage within the 90 days
immediately before the date you enrolled under this plan,
then the pre-existing conditions exclusion in your plan, if
any, will be waived. The determination of the 90 day
period will not include any waiting period that may be
imposed by your employer before you are eligible for
coverage.
* While this member notice is believed to be accurate as of the publication date, it is subject to change.
Please contact the Member Services Department, if you have any questions.
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An employee or dependent is eligible to enroll during a
special enrollment period if each of the following
conditions are met:
I
When you declined enrollment for you or your
dependent, you stated in writing that coverage under
another group health plan or other health insurance
was the reason for declining enrollment, if the
employer required such written notice and you were
given notice of the requirement and the consequences
of not providing the statement; and
I
When you declined enrollment for you or your
dependent, you or your dependent had COBRA
continuation coverage under another plan and that
COBRA continuation coverage has since been
exhausted; or
I
Special Enrollment Rules
To qualify for the special enrollment, individuals who meet
the above requirements must submit a signed request for
enrollment no later than 31 days after one of the events
described above. The effective date of coverage for
individuals who lost coverage will be the date of the
qualifying event. If you seek to enroll a dependent during
the special enrollment period, coverage for your
dependent (and for you, if also enrolling) will become
effective as of the date that the qualifying event occurred,
(for marriage, as of the enrollment date) once the
completed request for enrollment is received.
If the other coverage that applied to you or your
dependent when enrollment was declined was not
under a COBRA continuation provision, either the other
coverage has been terminated as a result of the loss of
eligibility or employer contributions toward that
coverage have been terminated. Loss of eligibility
includes a loss of coverage as a result of legal
separation, divorce, death, termination of employment,
or reduction in hours of employment.
For Certain Dependent Beneficiaries
If your Group Health Plan offers dependent coverage, it is
required to offer a dependent special enrollment period for
persons becoming a dependent through marriage, birth, or
adoption or placement for adoption. The dependent
special enrollment period will last for 31 days from the
date of the marriage, birth, adoption or placement for
adoption. The dependent may be enrolled during that time
as a dependent of the employee. If the employee is eligible
for enrollment, but not enrolled, the employee may also
enroll at this time. In the case of the birth or adoption of a
child, the spouse of the individual also may be enrolled as
a dependent of the employee if the spouse is otherwise
eligible for coverage but not already enrolled. If an
employee seeks to enroll a dependent during the special
enrollment period, the coverage would become effective
as of the date of birth, of adoption or placement for
adoption, or marriage.
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As of 7/1/2005 this addendum replaces the Health Insurance Portability and
Accountability Act Member Notice that appears elsewhere in this disclosure. See your
Benefit Summary for information regarding preexisting conditions exclusions.
The following information is provided to inform the member of certain provisions contained in the Group Health Plan, and
related procedures that may be utilized by the member in accordance with federal law.
Special Enrollment Rights
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or
group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents
lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage).
However, you must request enrollment within 31 days after your or your dependents’ other coverage ends (or after the
employer stops contributing toward the other coverage).
In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able
to enroll yourself and your dependents. However, you must request enrollment within 31 days after the marriage, birth,
adoption or placement for adoption.
To request special enrollment or obtain more information, contact your benefits administrator.
Request for Certificate of Creditable Coverage
Members of insured plan sponsors and members of self insured plan sponsors who have contracted with us to provide
Certificates of Prior Health Coverage have the option to request a certificate. This applies to terminated members, and it
applies to members who are currently active but who would like a certificate to verify their status. Terminated members can
request a certificate for up to 24 months following the date of their termination. Active member can request a certificate at
any time. To request a Certificate of Prior Health Coverage, please contact Member Services at the telephone number on the
back of your ID card.
*While this Member Notice is believed to be accurate as of the publication date, it is subject to change. Please contact the Member Services department
if you have any questions.
www.aetna.com
00.28.317.1 (7/05)
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9:59 AM
Page 11
Notice to Members
While this information is believed to be accurate as of the
print date, it is subject to change.
This material is for informational purposes only and is
neither an offer of coverage nor medical advice. It contains
only a partial, general description of plan benefits or
programs and does not constitute a contract. Aetna
arranges for the provision of health care services. However,
Aetna itself is not a provider of health care services and
therefore, cannot guarantee any results or outcomes.
Consult the plan documents [Group Agreement, Group
Insurance Certificate, Group Policy] to determine governing
contractual provisions, including procedures, exclusions
and limitations relating to the plan. The availability of a
plan or program may vary by geographic service area and
by plan design. These plans contain exclusions and some
benefits are subject to limitations or visit maximums.
With the exception of Aetna Rx Home Delivery®, all
participating physicians, hospitals and other health care
providers are independent contractors and are neither
agents nor employees of Aetna. Aetna Rx Home Delivery,
LLC. is a subsidiary of Aetna Inc. The availability of any
particular provider cannot be guaranteed, and provider
network composition is subject to change. Notice of the
change shall be provided in accordance with applicable
state law. Certain primary care physicians are affiliated with
integrated delivery systems or other provider groups (such
as independent practice associations and physician-hospital
organizations), and members who select these providers
will generally be referred to specialists and hospitals within
those systems or groups. However, if a system or group
does not include a provider qualified to meet member's
medical needs, member may request to have services
provided by nonsystem or nongroup providers. Member's
request will be reviewed and will require prior
authorization from the system or group and/or Aetna to be
a covered benefit.
For up-to-date information, please visit our DocFind® online
provider directory at www.aetna.com.
Aetna is the brand name used for products and services
provided by one or more of the Aetna group of subsidiary
companies. The Aetna company that underwrites or
administers benefits coverage includes Aetna Life Insurance
Company. For self-funded accounts, coverage is offered by
your employer with administrative services only provided
by Aetna Life Insurance Company.
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.
www.aetna.com
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