Important Disclosure Information*
Michigan
For HMO, Aetna Open Access®, Aetna Choice® POS, USAccess®, and QPOS® Members.
Plan of Benefits
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Your plan of benefits will be determined by your plan
sponsor. Covered services include most types of treatment
provided by primary care physicians, specialists and
hospitals. However, the health plan does exclude and/or
include limits on 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 medically necessary as defined
below and as determined by Aetna**. The information
that follows provides general information regarding Aetna
health plans. For a complete description of the benefits
available to you, including procedures, exclusions and
limitations, refer to your specific plan documents, which
may include the Schedule of Benefits, Certificate of
Coverage, Group Agreement, Group Insurance Certificate,
Group Insurance Policy and any applicable riders and
amendments to your plan.
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Neither the contract holder nor a Member is the agent
or representative of Aetna, its agents or employees, or
an agent or representative of any participating provider
or other person or organization with which Aetna has
made or hereafter shall make arrangements for services
under the certificate of coverage.
Participating physicians maintain the physician-patient
relationship with Members and are solely responsible to
Member for all medical services, which are rendered by
participating physicians.
Aetna cannot guarantee the continued participation of
any provider or facility with Aetna. In the event a PCP
terminates its contract or is terminated by Aetna; Aetna
shall provide notification to Members.
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.
Availability of Providers
Member Cost Sharing
Aetna cannot guarantee the availability or continued
participation of a particular provider. Either Aetna or any
participating provider may terminate the provider contract
or limit the number of members that will be accepted as
patients. If the PCP initially selected cannot accept
additional patients, the member will be notified and given
an opportunity to make another PCP selection. The
member is encouraged to cooperate with Aetna to select
another PCP. PCP’s provide coverage 24 hours a day, 365
days a year. After regular office hours the PCP or the
covering physician can be contacted through an answering
service or through another physician who is taking patient
calls.
Members are responsible for any copayments, coinsurance
and deductibles for covered services. These obligations are
paid directly to the provider or facility at the time the
service is rendered. Copayment, coinsurance and
deductible amounts are listed in your benefits summary
and plan documents.
Role of Primary Care Physicians (“PCPs”)
For most HMO plans, members are required to select a
private practice, PCP who participates in the Aetna
network. The PCP can provide primary care, as well as
coordinate and keep track of your overall care. The PCP
will issue referrals to participating specialists and facilities
for certain services. The Aetna plan determines coverage
for these services. Some services (such as inpatient
hospitalization) require pre-approval. Except for those
benefits described in the plan documents as direct access
benefits, plans with self-referral to participating providers
(Aetna Open Access or Aetna Choice POS), plans that
include benefits for nonparticipating provider services
(Aetna Choice POS, USAccess or QPOS), or in an
Independent Contractor Relationship
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No participating provider or other provider, institution,
facility or agency is an agent or employee of Aetna.
Neither Aetna nor any Member of Aetna is an agent or
employee of any participating provider or other
provider, institution, facility or agency.
* State mandates do not apply to self-funded plans. If you are unsure if
your plan is self-funded, please contact 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
01.28.302.1-MI (10/05)
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emergency, members will need to obtain a referral
authorization (“referral”) from their PCP before seeking
covered nonemergency specialty or hospital care.
Continuity of Care in the Event of
Insolvency
You may ask your PCP or call us at the number on your ID
card to find out if pre-approval is necessary, or check your
plan documents for details.
Aetna Health Participating Providers, as required by law,
are contractually obliged to continue to treat Members for
covered benefits under their Aetna plan even in the event
of Aetna or payor insolvency.
Participating PCPs are reviewed for licensure and other
credentials, quality of care, medical philosophy and office
standards before they join the network. Participating PCPs
are also re-reviewed on a regular basis.
Notification to Covered Persons of
Provider Termination
Covered persons are notified of PCP termination or change
of contract status by a system-generated letter advising
members following receipt of the PCP’s intent to terminate
the provider agreement. Member Services Representatives
are available to assist member with provider changes.
They can be reached by dialing the toll free number
identified on the Member ID card.
The PCP coordinates a member’s medical care, as
appropriate either by providing treatment or by issuing
referrals to direct the member to a participating provider.
The PCP can also order lab tests and x-rays, prescribe
medicines or therapies, and arrange hospitalization. Except
in a medical emergency or for certain direct access
specialist benefits as described in the certificate of
coverage, only those services which are provided by or
referred by a member’s PCP will be covered. Covered
benefits are described in the covered benefits section of
the certificate of coverage. It is a member’s responsibility
to consult with the PCP in matters regarding the member’s
medical care.
Aetna Health has in place a process of monitoring
significant participating provider activity. Provider
agreements provide for 90 days notification of either party
of intent to terminate the agreement. Marketing is
notified and notifies its customers of participating provider
additions and terminations. Members are notified by letter
from Aetna directly to their residence.
If the member’s PCP is a member of a Participating Medical
Group (“PMG”) or Independent Practice Association
(“IPA”), the member’s PCP will work with their PMG or IPA
to refer the member to specialist physicians who are
members of the PCP’s PMG or IPA. However, if your
medical needs extend beyond the scope of the affiliated
providers, you may request coverage for services provided
by nonaffiliated network physicians and facilities. In order
to be covered, services provided by nonaffiliated network
providers may require pre-approval from Aetna Health®
and/or the integrated delivery systems or other provider
groups.
Referral Policy
The following points are important to remember regarding
referrals
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If the member’s PCP performs, suggests, or recommends a
member for a course of treatment that includes services
that are not covered benefits, the entire cost of any such
noncovered services will be the member’s responsibility.
Transition of Care When a Provider
Terminates From the Aetna Network
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Aetna Health contracts are designed to provide transition
of care for covered persons should the treating
participating provider contract terminate during the course
of the Member’s active treatment by that provider.
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The referral is how the member’s PCP arranges for a
member to be covered for necessary, appropriate
specialty care and follow-up treatment.
The member should discuss the referral with their PCP
to understand what specialist services are being
recommended and why.
If the specialist recommends any additional treatments
or tests that are covered benefits, the member may
need to get another referral from their PCP prior to
receiving the services. If the member does not get
another referral for these services, the member may be
responsible for payment.
Except in emergencies, all hospital admissions and
outpatient surgery require a prior referral from the
member’s PCP and prior authorization by Aetna.
If it is not an emergency and the member goes to a
doctor or facility without a referral, the member must
pay the bill.
Referrals are valid for 60 days as long as the individual
remains an eligible member of the plan.
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In plans without out-of-network benefits, coverage for
services from nonparticipating providers requires prior
authorization by Aetna in addition to a special
nonparticipating referral from the PCP. When properly
authorized, these services are fully covered, less the
applicable cost-sharing.
members who select these PCPs will generally be referred
to specialists and hospitals within that system, association
or group. However, if your medical needs extend beyond
the scope of the affiliated providers, you may request
coverage for services provided by nonaffiliated network
physicians and facilities. In order to be covered, services
provided by nonaffiliated network providers may require
prior authorization from Aetna and/or the integrated
delivery systems or other provider groups.
Members should note that other health care providers (e.g.
specialists) may be affiliated with other providers through
systems, associations or groups. These systems,
associations or groups (“organization”) or, their affiliated
providers may be compensated by Aetna through a
capitation arrangement or other global payment method.
The organization then pays the treating provider directly
through various methods. Members should ask their
provider how that provider is being compensated for
providing health care services to the member and if the
provider has any financial incentive to control costs or
utilization of health care services by the member.
The referral provides that, except for applicable cost
sharing, the member will not have to pay the charges
for covered benefits, as long as the individual is a
member at the time the services are provided.
Direct Access
Under Aetna Choice POS, USAccess and QPOS plans a
member may directly access nonparticipating providers
without a PCP referral, subject to cost sharing
requirements. Even so, you may be able to reduce your
out-of-pocket expenses considerably by using participating
providers. Refer to your specific plan brochure for details.
If your plan does not specifically cover self-referred or
nonparticipating provider benefits and you go directly to a
specialist or hospital for nonemergency or nonurgent care
without a referral, you must pay the bill yourself unless the
service is specifically identified as a direct access benefit in
your plan documents.
Transplants and Other Complex
Conditions
Under Aetna Open Access and Aetna Choice POS plans a
member may directly access participating providers without
a PCP referral, subject to the terms and conditions of the
plan and cost sharing requirements. Participating providers
will be responsible for obtaining any required
preauthorization of services from Aetna. Refer to your
specific plan brochure for details.
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.
Direct Access Ob/Gyn Program
Emergency Care
This program allows female members to visit any
participating obstetrician or gynecologist for a routine well
woman exam, including a Pap smear, and for obstetric or
gynecologic problems. Obstetricians and gynecologists may
also refer a woman directly to other participating providers
for covered obstetric or gynecologic services. All health
plan preauthorization and coordination requirements
continue to apply. If your Ob/Gyn is part of an
Independent Practice Association (IPA), a Physician Medical
Group (PMG), an Integrated Delivery System (IDS) or a
similar organization, your care must be coordinated
through the IPA, the PMG or similar organization and the
organization may have different referral policies.
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.
Whether you are in or out of an Aetna HMO service area,
we simply ask that you follow the guidelines below when
you believe you need emergency care.
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Health Care Provider Network
All hospitals may not be considered participating for all
services. Your physician can contact Aetna to identify a
participating facility for your specific needs. Certain PCPs
are affiliated with integrated delivery systems, independent
practice associations (“IPAs”) or other provider groups, and
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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 as soon as possible.
What to Do Outside Your Aetna HMO
Service Area
card. The medications listed on the preferred drug list are
subject to change in accordance with applicable state law.
Members who are traveling outside their HMO service area
or students who are away at school are covered for
emergency and urgently needed care. Urgent care may be
obtained from a private practice physician, a walk-in clinic,
an urgent care center or an emergency facility. Certain
conditions, such as severe vomiting, earaches, sore throats
or fever, are considered “urgent care” outside your Aetna
HMO service area and are covered in any of the above
settings.
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, after reviewing information submitted to us by the
provider that supplied care, the nature of the urgent or
emergency problem does not qualify for coverage, it may
be necessary to provide us with additional information. We
will send you an Emergency Room Notification Report to
complete, or a Member Services representative can take
this information by telephone.
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
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.
Follow-up Care after Emergencies
All follow-up care should be coordinated by your PCP.
Follow-up care with nonparticipating providers is only
covered with a referral from your PCP and prior
authorization from Aetna. Whether you were treated
inside or outside your Aetna service area, you must obtain
a referral before any follow-up care can be covered. Suture
removal, cast removal, X-rays and clinic and emergency
room revisits are some examples of follow-up care.
Prescription Drugs
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
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
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purchasing drugs takes into account discounts, credits and
other amounts that it may receive from wholesalers,
manufacturers, suppliers and distributors.
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.”
If you use the Aetna Specialty PharmacySM 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.
How Aetna Compensates Your Health
Care Provider
All the physicians are independent practicing physicians
that are neither employed nor exclusively contracted with
Aetna. Individual physicians and other providers are in the
network by either directly contracting with Aetna and/or
affiliating with a group or organization that contract with
us.
Participating providers in our network are compensated in
various ways:
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Per individual service or case (fee for service at
contracted rates).
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Per hospital day (per diem contracted rates).
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Capitation (a prepaid amount per member, per month).
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Through Integrated Delivery Systems (IDS), Independent
Practice Associations (IPA), Physician Hospital
Organizations (PHO), Physician Medical Groups (PMG),
behavioral health organizations and similar provider
organizations or groups. Aetna pays these
organizations, which in turn may reimburse the
physician, provider organization or facility directly or
indirectly for covered services. In such arrangements, the
group or organization has a financial incentive to
control the cost of care.
One of the purposes of managed care is to manage the
cost of health care. Incentives in compensation
arrangements with physicians and health care providers are
one method by which Aetna attempts to achieve this goal.
In some regions, the Primary Care Physicians can receive
additional compensation based upon performance on a
variety of measures intended to evaluate the quality of care
and services the Primary Care Physicians provide to
Members. This additional compensation is based on the
scores received on one or more of the following measures
of the Primary Care Physician’s office:
Behavioral Health Network
Behavioral health care services are managed by an
independently contracted behavioral health care
organization. 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.
As with other coverage determinations, you may appeal
adverse behavioral health care coverage determinations in
accordance with the terms of your health plan.
The types of behavioral health benefits available to you
depends upon the terms of your health plan. If your health
plan includes behavioral health services, you may be
covered for treatment of mental health conditions and/or
drug and alcohol abuse problems. Members can determine
the type of behavioral health coverage available under the
terms of their plan by calling the Aetna Member Services
number on your ID card.
If you have an emergency, call 911 or your local
emergency hotline, if available. For routine services, access
covered behavioral health services available under your
health plan by the following methods:
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Call your PCP for a referral to the designated behavioral
health provider group.
When applicable, an employee assistance or student
assistance professional may refer you to your designated
behavioral health provider group.
Call the toll-free Behavioral Health Vendor number on
your ID card or, if no number is listed, call the Member
Services number on your ID card for the appropriate
information.
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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
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member satisfaction;
percentage of members who visit the office at least
annually;
medical record reviews;
the burden of illness of the members that have selected
the primary care physician;
management of chronic illnesses like asthma;
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diabetes and congestive heart failure;
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whether the physician is accepting new patients; and
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In the absence of such credible scientific evidence, the
[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.
participation in Aetna’s electronic claims and referral
submission program.
You are encouraged to ask your physicians and other
providers how they are compensated for their services.
Claims Payment for Nonparticipating
Providers and Use of Claims Software
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-bycase basis consistent with applicable policies.
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 or by accessing
other contractual arrangements. If such data is not
commercially available, our determination may be based
upon our own data or other sources. 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.
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. CPBs are
regularly updated and are therefore subject to change.
Aetna’s CPBs are available online at www.aetna.com.
Medically Necessary
“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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Preauthorization by Aetna
Clinically appropriate in accordance with generally
accepted standards of medical practice in term of
type, frequency, extent, site and duration.
Some services and supplies indicated in the plan
documents, such as maternity care, outpatient surgery,
home health care, and hospice care, also require prior
authorization by Aetna to determine if they are covered
benefits under the plan documents and if the service or
supply is medically necessary. The member’s PCP or
specialist will handle all prior authorizations for covered
benefits. Aetna will not retroactively deny covered nonemergency treatment that had prior authorization under
Aetna’s written policies.
Considered effective in accordance with generally
accepted standards of medical practice for the
illness, injury or disease; and
Not primarily for the convenience of the Member, or for
the physician or other health care provider; and
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.
Utilization Review/Patient Management
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.
The program assists members in receiving appropriate
healthcare and maximizing coverage for those healthcare
services.
“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.
Where such use is appropriate, our Utilization
Review/Patient Management staff uses nationally
recognized guidelines and resources, such as The Milliman
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Care Guidelines® to guide the precertification, concurrent
review and retrospective review processes. To the extent
certain Utilization Review/Patient Management functions
are delegated to IDS, IPAs, 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.
A representative will address your concern. If you are
dissatisfied with the outcome of your initial contact, you
may file a grievance with our Grievance Unit. If you are
not satisfied after filing a formal grievance, you may appeal
the decision. Your appeal will be decided in accordance
with the procedures applicable to your plan.
Aetna follows the state of Michigan PA251 of 2000,
known as the “Patients Right to Independent Review Act”
(PRIRA) effective October 1, 2000. This act creates an
external review process through the Division of Insurance
for adverse final determinations. A request for external
review shall not be made until Aetna’s internal grievance
procedure is exhausted. Members who request an
external review shall submit the request to the Division of
Insurance Health Plans Division. Aetna Health will provide
the member with the appropriate form to request an
external review.
You may contact the Michigan Commissioner of Insurance
at:
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.
Concurrent Review
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.
Office of Financial and Insurance Services
Consumer Services
P.O. Box 30220
Lansing, MI 48909-7720
Toll free phone: 1-877-999-6442
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.
When you file a request for external review, you will be
required to authorize the release of any medical records
that may be required to be reviewed for the purpose of
reaching a decision on the external review.
Retrospective Record Review
External 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 reviews all appeals of inpatient concurrent
review decisions for coverage 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.
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.
Complaints, Appeals and External
Review*
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.
Filing a Complaint or Appeal
For information on the Plan’s grievance procedures, you
may call Member Services at 1-800-208-8755 or refer to
your plan documents.
*This Complaints, Appeals 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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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).
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.
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 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 state mandated external
review procedures.
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. 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; 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.
Additional Information
Upon request, the following information can be supplied
to you: (1) Date of certification by applicable nationally
recognized Board or other organization; (2) names of
licensed facilities where providers have privileges; (3) prior
authorization requirements and limitations including
medication formulary restrictions; (4) information about
financial relationships between providers and the health
plan. To obtain this and further information on the health
plan you may call Member Services at the number found
on your I.D.card.
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.
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.
8
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.
Special Enrollment Rights
Request for Certificate of Creditable
Coverage
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).
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.
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 you benefits administrator.
* 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
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Notes
10
Notes
www.aetna.com
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, Schedule of Benefits, Certificate of
Coverage, 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.
The NCQA Accreditation Seal is a recognized symbol of
quality. NCQA recognition seals appear in the provider
directory next to those providers who have been duly
recognized. NCQA provider recognitions are subject to
change.
For up-to-date information, please visit our DocFind®
online provider directory at www.aetna.com or visit the
NCQA’s new top-level recognition listing at
recognition.ncqa.org.
Aetna is the brand name used for products and services
provided by one or more of the Aetna group of subsidiary
companies. In-network and out-of-network referred
benefits are underwritten by Aetna Health Inc. Self-referred
benefits are underwritten by Corporate Health Insurance
Company. For self-funded accounts, benefits coverage
offered by your employer, with administrative services only
provided by Aetna Life Insurance Company.
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.
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
