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Important Disclosure Information Missouri Aetna Health Network OnlySM, HMO, Aetna Open Access® HMO, Aetna Health Network OptionSM, QPOS® and Aetna Choice® POS Plans. State mandates do not apply to self-funded plans governed by ERISA. If you are unsure if your plan is self-funded and/or governed by ERISA, see your benefits administrator. Specific plan documents supersede general disclosures contained within, as applicable. THIS HMO MAY HAVE RESTRICTIONS REGARDING WHICH PHYSICIANS OR OTHER HEALTH CARE PROVIDERS AN HMO MEMBER MAY USE. PLEASE CONSULT YOUR PLAN DOCUMENTS OR THIS DISCLOSURE FOR DETAILS. IF YOU HAVE QUESTIONS, PLEASE WRITE TO US AT THE ADDRESS BELOW OR CALL US TOLL FREE AT 1-888-982-3862. Member Financial Responsibility Cost sharing refers to the portion of medical services that you pay out of your own pocket. Refer to your plan documents to see which of the following cost-sharing provisions apply to your plan: ■ Copay – This may be a flat fee that you pay directly to the health care provider at the time of service. ■ The HMO provides coverage for certain services and supplies. For a complete description of the coverage provisions, health care benefits, benefit maximums, benefit limitations and exclusions, please refer to the Certificate of Coverage. This information shall also be made available to prospective enrollees upon request. Coinsurance – This is a percentage of the fees that you must pay toward the cost of some covered medical expenses. Your health care provider will bill you for this amount. ■ 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. Plan Benefits ■ Inpatient Hospital Deductible – The amount of covered inpatient hospital expenses you pay for each hospital confinement before benefits are paid. This deductible is in addition to any other copayments or deductibles under your plan. ■ Emergency Room Deductible – The amount of covered hospital emergency room expenses you pay each year before benefits are paid. A separate hospital emergency room deductible applies to each visit by a person to a hospital emergency room unless the person is admitted to the hospital as an inpatient within 24 hours after a visit to a hospital emergency room. Aetna Health Inc. 1350 Elbridge Payne Rd. Suite 201 Chesterfield, MO 63017 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 to follow, 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. * Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. The companies that offer, underwrite or administer benefits coverage include Aetna Health Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company. www.aetna.com 01.28.302.1-MO G (9/10) 1 Members are responsible for all coinsurance, copayments and deductibles applicable under their particular plan and may be responsible for premiums depending on the terms of their plan. Please refer to the plan documents for a more detailed description of these responsibilities and the provisions pertaining to annual limits on your financial responsibility and limits on payments for covered services, if applicable. In addition, you may also be financially responsible for services that are: ■ provided by a health care provider who is not a participating provider; ■ provided by a provider without obtaining any required authorization; ■ not covered under the health plan; or ■ You may choose a different PCP for each member of your family. When you enroll, indicate the name of the PCP you have chosen on your enrollment form. Or, call Member Services after you enroll to tell us your selection. The name of your PCP will appear on your Aetna ID card. You may change your selected PCP at any time. If you change your PCP, you will receive a new ID card. related to out-of-area expenses. (out-of-area expenses are reimbursed by some health plans. Refer to your plan design overview to determine if your plan does.) Your PCP can provide primary health care services as well as coordinate your overall care. You should consult your PCP when you are sick or injured to help determine the care that is needed. If your plan requires referrals, your PCP should issue a referral to a participating specialist or facility for certain services. (See Referral Policy for details.) Participating Providers To select a participating provider, you may use our DocFind® directory at www.aetna.com or contact Member Services. Referral Policy Check your plan documents to see if your plan requires PCP referrals for specialty care. Your plan documents will also list any direct access benefits that do not require referrals. If referrals are required, you must see your PCP first before visiting a specialist or other outpatient provider for nonemergency or nonurgent care. Your PCP will issue a referral for the services needed. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. The availability of any particular provider cannot be guaranteed for referred or in-network benefits, and provider network composition is subject to change. If you do not get a referral when a referral is required, you may have to pay the bill yourself, or the service will be treated as nonpreferred if your plan includes out-ofnetwork benefits. Some services may also require prior approval by us. See the Precertification section and your plan documents for details. Not every provider listed in the directory will be accepting new patients. Although we have identified providers who were not accepting patients as known to us at the time the provider directory was created, the status of a provider's practice may have changed. For the most current information, you may contact the provider or Member Services at the toll-free number listed on your ID card. The following points are important to remember regarding referrals. ■ The referral is how your PCP arranges for you to be covered at the in-network benefit level for necessary, appropriate specialty care and follow-up treatment. ■ You should discuss the referral with your PCP to understand what specialist services are being recommended and why. ■ If the specialist recommends any additional treatments or tests beyond those referred by the PCP, you may need to get another referral from your PCP before receiving the services. ■ Except in emergencies, all inpatient hospital services require a prior referral from your PCP and prior authorization by Aetna. Your Primary Care Physician Check your plan documents to see if your plan requires you to select a primary care physician (PCP). If a PCP is required, you must choose a doctor from the Aetna network. You can look up network doctors in a printed Aetna Physician Directory, or visit our DocFind® directory at www.aetna.com. If you do not have Internet access and would like a printed directory, please contact Member Services at the toll-free number on your ID card and request a copy. Product PCP Required? Referrals Required? HMO Precertification Required? Yes Yes Yes Aetna Open Access HMO Encouraged No Yes Health Network Only Encouraged No Yes Yes Yes Yes Encouraged No Yes QPOS Aetna Choice POS 2 ■ Referrals are valid for one year as long as you remain an eligible member of the plan; the first visit must be within 90 days of referral issue date. ■ 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. ■ similar organization, your care must be coordinated through the IPA, the PMG or similar organization and the organization may have different referral policies. Precertification Some health care services, like hospitalization and certain outpatient surgery, require “precertification.” This means the service must be approved by Aetna before it will be covered under the plan. Check your plan documents for a complete list of services that require this approval. When reviewing a precertification request, we will verify your eligibility and make sure the service is a covered expense under your plan. We also check the cost-effectiveness of the service and we may communicate with your doctor if necessary. If you qualify, we may enroll you in one of our case management programs and have a nurse call to make sure you understand your upcoming procedure. The referral (and a precertification, if required) provides that, except for applicable cost sharing (that is, copays, coinsurance and/or deductibles), you will not have to pay the charges for covered expenses, as long as the individual seeking care is a member at the time the services are provided. Direct Access When you visit a doctor, hospital or other provider that participates in the Aetna network, someone at the provider’s office will contact Aetna on your behalf to get the approval. Under Aetna Open Access HMO and Aetna Choice POS plans you 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 documents for details. If your plan allows you to go outside the Aetna network of providers, you will have to get that approval yourself. In this case, it is your responsibility to make sure the service is precertified, so be sure to talk to your doctor about it. If you do not get proper authorization for out-of-network services, you may have to pay for the service yourself. Aetna Choice POS and QPOS plans have direct-access benefits. Direct-access benefits allow you to directly access participating providers and nonparticipating providers without a PCP referral, subject to additional 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. You cannot request precertification after the service is performed. To precertify services, call the number shown on your Aetna ID card. Services requiring Precertification* If your plan does not specifically cover direct-access benefits (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. 1. Inpatient confinements: ■ ■ Rehabilitation facility ■ Inpatient hospice ■ This program allows female members to visit, without a referral, any participating obstetrician or gynecologist for a routine well-woman exam, including a breast exam, mammogram and 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 Skilled nursing facility ■ Direct Access Ob/Gyn Program Surgical and non-surgical, excluding vaginal or Caesarean deliveries Observation stays greater than 23 hours 2. Reconstructive procedures that may be considered cosmetic ■ Blepharoplasty/canthopexy/canthoplasty ■ Excision of excessive skin due to weight loss ■ Rhinoplasty/rhytidectomy ■ Gastroplasty/gastric bypass ■ Pectus excavatum repair ■ Breast reconstruction/breast enlargement ■ Breast reduction/mammoplasty * The term precertification means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company’s clinical criteria for coverage. www.aetna.com 3 ■ Surgical treatment of gynecomastia ■ Lipectomy or excess fat removal > Pegasys® ■ Sclerotherapy or surgery for varicose veins > Peg Intron® ■ Interferons when used for hepatitis C 3. Artificial lumbar disc surgery > Rebetron® 4. Uvulopalatopharyngoplasty, including laser-assisted procedures > Roferon A® 5. Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint > Infergen® > Intron A® 10. All home health care services, including home uterine monitoring 6. Dental implants and oral appliances 11. Selected durable medical equipment 7. Elective (non-emergent) transportation by ambulance or medical van, and all transfers via air ambulance ■ ■ ■ Limb prosthetics ■ Intensity modulated radiation therapy (IMRT), except for brain, head, neck, spine and prostate Clinitron and electric beds ■ 8. The following conditionally eligible services** Electric or motorized wheelchairs and scooters Customized braces ■ Stereotactic radiosurgery ■ Somatosensory evoked potential studies ■ Cognitive skills development 12. In-network level of benefits for nonparticipating physicians and providers for non-emergent services***, only when there is an identified network deficiency. ■ Hyperbaric oxygen therapy 13. Special programs ■ Osteochondral allograft/knee ■ Cochlear device and/or implantation ■ Osseointegrated implant ■ Percutaneous implant of neuroelectrode array, epidural ■ ■ ■ To precertify mental health or substance abuse services, see member’s ID card. ■ Beginning Right® Maternity Management Program, including genetic testing, antenatal testing, perinatal consultations and counseling: 1-800-272-3531 GI tract imaging through capsule endoscopy ■ BRCA genetic testing: 1-877-794-8720 Botox injections — botulinum toxin type A ■ Infertility Program: 1-800-575-5999 Alpha 1-proteinase inhibitor — human ■ Pre-implantation genetic testing: 1-800-575-5999 ■ Negative pressure wound therapy pump ■ ■ High-frequency chest wall oscillation generator system National Medical Excellence Program®: 1-877-212-8811 for all major organ transplant evaluations and transplants including, but not limited to, kidney, liver, heart, lung and pancreas, and bone marrow replacement or stem cell transfer after highdose chemotherapy ■ Effective May 1, 2007 for all members with plans applicable to this precertification list: Outpatient imaging precertification for CTs, coronary computed tomographic angiography, MRI/MRA, nuclear cardiology, PET scans through regional-specific managed service organizations (MedSolutions, Care Core National and National Imaging Associates).**** ■ 9. Medical injectables ■ Intravenous immunoglobulin (IVIG) Synagis (intake by Aetna Specialty Pharmacy® at 1-866-782-2779) ■ ■ Growth hormone ■ Blood-clotting factors ** All services deemed “never effective” are excluded from coverage. Aetna defines a service as “never effective” when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. Visit the secure website, available through www.aetna.com, for more information. Click on “Claims,” “CPT/HCPCS Coding Tool,” “Clinical Policy Code Lookup.” *** Aetna Choice and QPOS benefits plans may include the option for members to go outside the network and receive reduced benefits. **** This applies to HMO plans only. 4 Additional Assistance and Information for Providers ■ For information about Clinical Policy Bulletins or our DocFind® directory, please see your plan documents or refer to those topics in this disclosure document. ■ Contact Aetna Pharmacy Management at 1-800-414-2386 for precertification of oral medications only. ■ Contact Aetna Specialty Pharmacy at 1-866-782-2779 for information on injectable medications not listed. ■ All hospitals may not be considered Aetna participating providers for all the services that you need. Your physician can contact Aetna to identify a participating facility for your specific needs. Certain PCPs are affiliated with IDSs, IPAs or other provider groups. If you select one of these PCPs you will generally be referred to specialists and hospitals within that system, association or group (“organization”). However, if your medical needs extend beyond the scope of the affiliated providers, you may request coverage for services provided by Aetna network providers that are not affiliated with the organization. In order to be covered, services provided by network providers that are not affiliated with the organization may require prior authorization from Aetna and/or the IDS or other provider groups. You should note that other health care providers (e.g. specialists) may be affiliated with other providers through organizations. Electronic submission of precert requests and inquiries is preferred. Call our Provider Service Center at 1-800-624-0756 for confirmation of member benefits and eligibility. ■ Health Care Provider Network Precertification approvals are valid for six months in all states. Behavioral health services requiring precertification/authorization For up-to-date information about how to locate inpatient and outpatient services, partial hospitalization and other behavioral health care services, please visit our DocFind directory at www.aetna.com. If you do not have Internet access and would like a printed provider directory, please contact Member Services at the toll-free number on your Aetna ID card and request a copy. This applies only to services covered under the member’s benefits plan. ■ Inpatient admissions ■ Residential Treatment Center (RTC) admissions ■ Partial Hospitalization Programs (PHPs) ■ Intensive Outpatient Programs (IOPs) Advance Directives ■ Psychological testing There are three types of advance directives: ■ Neuropsychological testing ■ Outpatient Electroconvulsive Therapy (ECT) ■ Biofeedback ■ Amytal interview ■ Hypnosis ■ Psychiatric home care services ■ Outpatient detoxification ■ ■ Do-not-resuscitate order – states that you don’t want to be given CPR if your heart stops or be intubated if you stop breathing. You can create an advance directive in several ways: ■ ■ Ask for an advance directive form at state or local offices on aging, bar associations, legal service programs, or your local health department. ■ Work with a lawyer to write an advance directive. ■ Self-funded plans with plan sponsors who have expressly purchased precertification requirements. There are a small number of plan sponsors whose plans require preauthorization for all outpatient services. Get an advance medical directive form from a health care professional. Certain laws require health care facilities that receive Medicare and Medicaid funds to ask all patients at the time they are admitted if they have an advance directive. You don’t need an advance directive to receive care. But we are required by law to give you the chance to create one. Create an advance directive using computer software designed for this purpose. Behavioral health benefits plans that we administer, but do not manage ■ Living will – spells out the type and extent of care you want to receive. ■ Exceptions to this policy This policy applies to all Aetna plans with the exception of: ■ Durable power of attorney – appoints someone you trust to make medical decisions for you. To obtain precertification/authorization for mental health, substance abuse or behavioral health services, refer to the member’s ID card for the toll-free Member Services or Aetna Behavioral Health phone number. www.aetna.com 5 ■ or fever, are considered "urgent care" outside your Aetna service area and are covered in any of the above settings. If you are not satisfied with the way Aetna handles advance directives, you can file a complaint with your Medicare State Certification Agency. Visit www.medicare.gov for information on specific state agencies or call 1-800-MEDICARE (1-800-633-4227) (TTY/TDD: 1-877-486-2048). 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. Source: American Academy of Family Physicians. Advanced Directives and Do Not Resuscitate Orders. January 2009. Available at http://familydoctor.org/003.xml?printxml. Accessed February 20, 2009. 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. Transplants and Other Complex Conditions Our National Medical Excellence Program® and other specialty programs help you access covered services 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, you may be limited to only those facilities participating in these programs when needing a transplant or other complex condition covered. After-Hours Care You may call your provider’s office 24 hours a day, 7 days a week if you have medical questions or concerns. You may also consider visiting participating Urgent Care facilities. See your plan documents for cost-sharing provisions for urgent care services. Note: There are exceptions depending on state requirements. Emergency Care Emergency Determination 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. When enrollee receives emergency services that require immediate post-evaluation or post-stabilization services, we will provide authorization within 60 minutes of receiving request. If authorization decision is not made within 30 minutes, such services shall be deemed approved. 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 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 you pay to your pharmacy for a prescription drug. In addition, in circumstances where your prescription plan utilizes copayments or coinsurance calculated on a percentage of the cost of a drug or a deductible, it is possible for your cost to be higher for a preferred drug than it would for a nonpreferred drug. For information regarding how medications are reviewed and selected for the preferred drug list, please refer to www.aetna.com or the Aetna Preferred Drug (Formulary) Guide. Printed Preferred Drug Guide information will be provided, upon request or if 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. ■ 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 doctor or PCP. Notify your doctor or 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 doctor, PCP or Aetna as soon as possible. What to Do Outside Your Aetna Service Area If you are traveling outside your Aetna service area or if you are a student who is away at school; you 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 6 applicable, annually for current members and upon enrollment for new members. For more information, call Member Services at the toll-free number on your ID card. The medications listed on the preferred drug list are subject to change in accordance with applicable state law. Home Delivery's and Aetna Specialty Pharmacy’s cost of purchasing drugs takes into account discounts, credits and other amounts they may receive from wholesalers, manufacturers, suppliers and distributors. The negotiated charge with Aetna Rx Home Delivery, LLC. and Aetna Specialty Pharmacy may be higher than the cost of purchasing drugs and providing pharmacy services. 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. Updates to the Drug Formulary For up-to-date formulary information, visit www.aetna.com/formulary/ or call Member Services at the toll-free number on your Aetna ID card. If you do not have Internet access, you may contact Member Services at the toll-free number on your ID card to find out how a specific drug is covered. 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 you to use such drugs, your physician, you or your authorized representative (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. Behavioral Health Network Behavioral health care services are managed by Aetna. As a result, Aetna is responsible for making initial coverage determinations and coordinating referrals to the Aetna 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. 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 that requires a trial of one or more "prerequisite-therapy" medications before a "steptherapy" medication will be covered. If it is medically necessary for you to use a medication subject to these requirements prior to completing the step therapy, your physician, you or your authorized representative can request coverage of such drug as a medical exception. In addition, some benefit plans include a mandatory generic drug cost-sharing requirement. In these plans, you may be required to pay the difference in cost between a covered brand-name 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. The type of behavioral health benefits available to you depends on the terms of your health plan and state law. If your health plan includes behavioral health services, you may be covered for mental health conditions and/or drug and alcohol abuse services, including inpatient and outpatient services, partial hospitalizations and other behavioral health services. You can determine the type of behavioral health coverage available under the terms of your plan and how to access services by calling the Aetna Member Services number listed 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: ■ ■ Ask your treating physician(s) 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 Aetna Rx Home Delivery® mailorder prescription program or the Aetna Specialty Pharmacy® specialty drug program, you will be acquiring these prescriptions through an affiliate of Aetna. Aetna Rx Where required by your plan, call your PCP for a referral to the designated behavioral health provider group. ■ 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. Call the toll-free Behavioral Health number (where applicable) listed on your ID card or, if no number is listed, call the Member Services number listed on your ID card for the appropriate information. When applicable, an employee assistance or student assistance professional may refer you to your designated behavioral health provider group. You can access most outpatient therapy services without a referral or preauthorization. However, you should first consult Member Services to confirm that any such outpatient therapy services do not require a referral or preauthorization. www.aetna.com 7 Behavioral Health Provider Safety Data Available Prevailing Charge Plans Step 1: We review the data. We get information from Ingenix, which is owned by United HealthCare. Health plans send Ingenix copies of claims for services they received from providers. The claims include the date and place of the service, the procedure code, and the provider’s charge. Ingenix combines this information into databases that show how much providers charge for just about any service in any zip code. For information about our Behavioral Health provider network safety data, visit www.aetna.com/docfind and select the “Get info on Patient Safety and Quality” link. If you do not have Internet access, you may call Member Services at the toll-free number shown on your Aetna ID card to request a printed copy of this information. Step 2: We calculate the portion we pay. For most of our health plans, we use the 80th percentile to calculate how much to pay for out-of-network services. Payment at the 80th percentile means 80 percent of charges in the database are the same or less for that service in a particular zip code. Behavioral Health Depression Prevention Programs Aetna Behavioral Health offers two prevention programs for our members: Perinatal Depression Education, Screening and Treatment Referral Program, also known as Beginning Right® Depression Program, and Identification and Referral of Adolescent Members Diagnosed With Depression Who Also Have Comorbid Substance Abuse Needs. For more information on either of these prevention programs and how to use the programs, ask Member Services for the phone number of your local Care Management Center. If there are not enough charges (less than 9) in the databases for a service in a particular zip code, we may use “derived charge data” instead. “Derived charge data” is based on the charges for comparable procedures, multiplied by a factor that takes into account the relative complexity of the procedure that was performed. We also use derived charge data for our student health plans and Aetna Affordable Health Choices® plans. How Aetna Pays In-Network Providers We also may consider other factors to determine what to pay if a service is unusual or not performed often in your area. These factors can include: All the providers in our network directory are independent. They are free to contract with other health plans. Providers join our network by signing contracts with us. Or they work for organizations that have contracts with us. We pay network providers in many different ways. Sometimes we pay a rate for a specific service and sometimes for an entire course of care (for example, a flat fee for a pregnancy without complications). In certain circumstances, some providers are paid a pre-paid amount per month per Aetna member (capitation). We may also provide additional incentives to reward physicians for delivering cost-effective quality care. ■ The complexity of the service ■ The degree of skill needed ■ The provider’s specialty ■ The prevailing charge in other areas ■ Aetna’s own data Step 3: We refer to your health plan. We pay our portion of the prevailing charge as listed in your health plan. You pay your portion (called “coinsurance”) and any deductible. We pay some network hospitals by the day (per diem) and we pay others in a different way, such as a percentage of their standard billing rates. We encourage you to ask your providers how they are paid for their services. For example, your out of network doctor charges $120 for an office visit. Your plan covers 70 percent of the “reasonable,” “usual and customary” or “prevailing” charge. Let's say the prevailing charge is $100. And let's say you already met your deductible. Aetna would pay $70. You would pay the other $30. Your doctor may also bill you for the $20 difference between the prevailing charge ($100) and the billed charge ($120). In this case, your doctor could bill you for a total of $50. How Aetna Pays Out-of-Network Providers Some of our plans pay for services from providers who are not in our network. Many plans pay for services based on what is called the “reasonable,” “usual and customary” or “prevailing” charge. Other plans pay based on our standard fees for care received from a network provider, or based on a percentage of Medicare’s fees. When we pay less than what your provider charges, your provider may require you to pay the difference. This is true even if you have reached your plan’s out-of-pocket maximum. Here is how we figure out what we will pay for each type of plan. The Prevailing Charge Databases The New York State Attorney General (NYAG) investigated the conflicts of interest related to the ownership and use of Ingenix data. Under an agreement with the NYAG, UnitedHealth Group agreed to stop using the Ingenix databases when an independent database (not owned by a health insurer) is created. In a separate agreement with NYAG in January 2009, Aetna agreed to use this new 8 database when it is ready. We also will work with the new database owner to create online tools to give you better information about the cost of your care when using providers outside our network. Technology Review We review new medical technologies, behavioral health procedures, pharmaceuticals and devices to determine which one should be covered by our plans. And we even look at new uses for existing technologies to see if they have potential. To review these innovations, we may: Fee Schedule Plans Step 1: We compare the provider’s bill to our fee schedule and your health plan. Your plan may say that we will pay the provider based on our fee schedule for network doctors, or a certain percentage of that fee schedule, or a certain percentage of what Medicare pays. For example, your plan may say we pay 125 percent of what we pay a network doctor for the same service. ■ Study published medical research and scientific evidence on the safety and effectiveness of medical technologies ■ Consider position statements and clinical practice guidelines from medical and government groups, including the federal Agency for Health Care Research and Quality Let’s say you have your appendix removed. Our network rate for that surgery is $1,600. We multiply $1,600 by 125 percent to get $2,000. We call this the “recognized” or “allowed” amount. ■ Seek input from relevant specialists and experts in the technology ■ Determine whether the technologies are experimental or investigational Step 2: We calculate the portion we pay. Your plan also says that you must pay “coinsurance.” This is your share of the “recognized” or "allowed" amount. You can find out more on new tests and treatments in our Clinical Policy Bulletins. See Clinical Policy Bulletins below for more information. For example, your share may be 30 percent. In that case, we pay 70 percent of the $2,000 allowed amount, which is $1,400. You pay your provider your 30 percent coinsurance, which is $600. Your provider may also ask you to pay the $500 difference between the $2,500 bill and the $2,000 “recognized” or “allowed” amount. In this case, your provider could bill you $1,100 in total. 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: Exceptions Some “prevailing charge" plans set the prevailing charge at a different percentile. For some claims (like those from hospitals and outpatient centers) we may use other information and data sources to determine the charge. And some of our plans pay based on a different kind of fee schedule. Also, for some non-participating providers we may pay based on other contractual arrangements. ■ ■ Clinically appropriate in accordance with generally accepted standards of medical practice in terms of type, frequency, extent, site and duration, and considered effective for the illness, injury or disease; and ■ Not primarily for the convenience of you, or for the physician or other health care provider; and ■ Our provider claims codes and payment policies may also affect what we pay for a claim. Aetna may 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. The effects of these policies will be reflected in your Explanation of Benefits documents. In accordance with generally accepted standards of medical practice; 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. For these purposes “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, or otherwise consistent with physician specialty society recommendations and the views of physicians practicing in relevant clinical areas and any other relevant factors. How Aetna Pays for Out-of-Network Behavioral Health Benefits We negotiate rates with psychiatrists, psychologists, counselors and other appropriately licensed and credentialed behavioral health care providers to help you save money. We refer to these providers as being "in our network." www.aetna.com 9 Clinical Policy Bulletins 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 IDSs, IPAs or other provider groups ("Delegates"), such Delegates utilize criteria that they deem appropriate. Utilization Review/Patient Management policies may be modified to comply with applicable state law. Clinical Policy Bulletins (CPBs) describe our policy determinations of whether certain services or supplies are medically necessary or experimental or investigational, based on 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. Aetna CPBs do not constitute medical advice. Treating providers are solely responsible for medical advice and for your treatment. You should discuss any CPB related to your coverage or condition with your treating provider. While Aetna 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. You and your providers will need to consult the benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Only medical professionals 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 you of the appeal process. For more information concerning utilization management, you may request a free copy of the criteria we use to make specific coverage decisions by contacting Member Services. You may also visit www.aetna.com/about/cov_det_policies.html to find our Clinical Policy Bulletins and some utilization review policies. Doctors or health care professionals who have questions about your coverage can write or call our Patient Management department. The address and phone number are on your ID card. CPBs are regularly updated and are therefore subject to change. You can find them online at www.aetna.com under “Members” and then “Health Coverage Information.” If you do not have Internet access, please contact Member Services at the toll-free number on your ID card for information about specific Clinical Policy Bulletins. Initial Determinations For Initial Determinations, we will make the initial determination within 2 working days of obtaining all necessary information. If the service is certified, we will notify your health care provider by telephone within 24 hours. Written or electronic confirmation will be provided to you or your designated representative and your provider within 2 working days of telephone notice. If there is an adverse determination, we will notify your provider by telephone within 24 hours. Written/electronic confirmation will be provided within 1 working day of telephone notice. Utilization Review/Patient Management We have 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 you in receiving appropriate health care and maximizing coverage for those health care services. You can avoid receiving an unexpected bill with a simple call to Member Services. You can find out if your preventive care service, diagnostic test or other treatment is a covered benefit — before you receive care — just by calling the toll-free number on your ID card. In certain cases, we review your request to be sure the service or supply is consistent with established guidelines and is a covered benefit under your plan. We call this “utilization management review.” Concurrent Review Concurrent review is a review conducted while a patient is confined on an inpatient basis. 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. We follow specific rules to help us make your health a top concern: ■ Aetna employees are not compensated based on denials of coverage. ■ For concurrent review determinations, we must make the determination within 1 working day of obtaining all necessary information. If service is certified, we will notify your provider by telephone within 1 working day. Written/electronic confirmation will be provided to you or your designated representative, and your provider within 1 working day of telephone notice. If there is an adverse determination, we will notify your provider by telephone within 24 hours. Written/electronic confirmation will be We do not encourage denials of coverage. In fact, our utilization review staff is trained to focus on the risks of members not adequately using certain services. 10 About Coverage Decisions Sometimes we receive claims for services that may not be covered by your health benefits plan. It can be confusing — even to your doctors. Our job is to make coverage decisions based on your specific benefits plan. provided within 1 working day of telephone notice. Service shall be continued without liability to you until you have been notified. 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 you upon discharge from an inpatient stay. If a claim is denied, we’ll send you a letter to let you know. If you don’t agree you can file an appeal. To file an appeal, follow the directions in the letter that explains that your claim was denied. Our appeals decisions will be based on your plan provisions and any state and federal laws or regulations that apply to your plan. You can learn more about the appeal procedures for your plan from your plan documents. Retrospective Record Review Retrospective review is a review conducted after the patient has been discharged from the hospital or facility. 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 of health care services. Our effort to manage the services provided to you includes the retrospective review of claims submitted for payment, and of medical records submitted for potential quality and utilization concerns. Filing a Complaint, Grievance or Appeal Grievance Review We are committed to addressing your coverage issues, complaints and problems. If you have a coverage issue or other problem, call Member Services at the toll-free number on your ID card or e-mail us from your secure Aetna Navigator® member website. Click on “Contact Us” after you log on. You can also contact Member Services 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. For retrospective review determinations, we will make the determination within 30 working days of obtaining all necessary information. Notice of the determination will be provided to you in writing within 10 days of the determination. If you are dissatisfied with the outcome of your initial contact, you may file an appeal. Your appeal will be decided in accordance with the procedures applicable to your plan and applicable state law. Refer to your plan documents for details regarding your plan's appeal procedure. We have written procedures to address failure of the provider, member, or designated representative of member, to provide the necessary information. For cases in which you or your provider will not release the necessary information, we may deny the services. You, your designated representative, or your provider acting on your behalf may submit a grievance. We will prepare a written acknowledgment of the grievance. Reconsideration For initial and concurrent review of services, we will give your provider an opportunity to request, on your behalf, a reconsideration of an adverse determination by the individual making the determination. Reconsideration shall occur within 1 working day of receipt of the request and shall be conducted between the provider and reviewer, or a clinical peer designated by the reviewer if the reviewer is not available. If this reconsideration does not resolve the issue, you, your designated representative, or your provider on your behalf may appeal the adverse determination. Reconsideration is not a prerequisite to an appeal. The notice will: 1. acknowledge the grievance within 5 working days of receipt of the grievance 2. invite you to provide any additional information to assist us in handling and deciding the grievance 3. inform you of your right to have an uninvolved Aetna representative assist you in understanding the grievance process 4. inform you as to when a response should be forthcoming All grievances will be investigated within 20 working days of receipt. Within 5 working days after the investigation is completed, someone who was not involved in the circumstances giving rise to the grievance or its investigation will decide upon the appropriate resolution of the grievance and notify the enrollee in writing of the decision and the right to file an appeal for a second level review. Within 15 working days after the investigation is completed, we will notify the person who submitted the Complaints, Appeals and External Review 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. www.aetna.com 11 Expedited reviews are available when your physician certifies that a delay in service would jeopardize your 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 you to pay a filing fee as part of the state mandated program). grievance of the decision. A preservice grievance of a plan required preauthorization will be resolved in 15 calendar days of the receipt of the request. All other grievances will be resolved in 30 calendar days of receipt of the request. Grievance Hearing (Second Level Review) You are entitled to a second level review by a committee if Aetna upholds and adverse benefit determination at the first level of appeal. A preservice grievance of a plan required pre-authorization will be resolved in 15 calendar days of the receipt of the request. All other grievances will be resolved in 30 calendar days of receipt of the request. 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 or investigational coverage decisions. These state mandates may not apply to self-funded plans. Expedited Grievance In the event a complaint requires specific action, and you or we believe serious medical consequences will arise in the near future, you may request and will receive expedited review of your grievance. A grievance of a decision involving urgent care including urgent concurrent care will be resolved within 36 hours (each level). For details about your plan's appeal process and the availability of an external review process, visit www.aetna.com to print an external review request form or call the Member Services toll-free number on your ID card. You also may call your state insurance or health department or consult their website for additional information regarding state mandated external review procedures. Missouri Department of Insurance You may contact the Department of Insurance for assistance regarding any inquiry, grievance or grievance appeal at: Member Rights & Responsibilities Missouri Department of Insurance Office of the Director 301 West High Street Room 530 Jefferson City, Missouri 65101 1-800-726-7390 You have the right to receive a copy of our Member Rights and Responsibilities Statement. This information is available to you at www.aetna.com/about/MemberRights. You can also obtain a print copy by contacting Member Services at the number on your ID card. Members covered under insured plans may obtain additional information from state regulatory agencies regarding member rights. The state regulatory agency website for Missouri is: www.insurance.state.mo.us. Member Services To file a complaint or an appeal, for additional information regarding copayments and other charges, information regarding benefits, to obtain copies of plan documents, information regarding how to file a claim or for any other question, you can contact Member Services at the toll-free number on your ID card, or email us from your secure Aetna Navigator member website at www.aetna.com. Click on “Contact Us” after you log on. External Review We established an external review process to give you the opportunity of requesting an objective and timely independent review of certain coverage denials. Once the applicable internal appeal process has been exhausted, you may request an external review of the decision for the coverage denial if: (a) you would be financially responsible for the cost of services; (b) the amount of the service(s) is more than $500, and (c) is based on lack of medical necessity or on the experimental or investigational nature of the proposed service or supply. Standards may vary by state, and several states have external review processes that may apply to your plan. Interpreter/Hearing Impaired When you require assistance from an Aetna representative, call us during regular business hours at the number on your ID card. Our representatives can: ■ Help you get referrals ■ Find care outside your area ■ Advise you on how to file complaints and appeals ■ Connect you to behavioral health services (if included in your plan) ■ 12 Answer benefits questions ■ If a request meets the requirement for an external review, an Independent Review Organization (IRO) will assign the case to an external physician reviewer with appropriate expertise for an independent decision 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. Find specific health information ■ 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 anti-fraud activities; performance measurement and outcomes assessment; health claims analysis and reporting; health services research; data and information systems management; compliance with legal and regulatory requirements; formulary management; litigation proceedings; transfer of policies or contracts to and from other insurers, HMOs and third party administrators; underwriting activities; and due diligence activities in connection with the purchase or sale of some or all of our business. We consider these activities key for the operation of our health plans. To the extent permitted by law, we use and disclose personal information as provided above without your consent. However, we recognize that you may not want to receive unsolicited marketing materials unrelated to your health benefits. We do not disclose personal information for these marketing purposes unless you consent. We also have policies addressing circumstances in which you are unable to give consent. Provide information on our Quality Management program, which evaluates the ongoing quality of our services Multilingual hotline — 1-888-982-3862 (140 languages are available. You must ask for an interpreter.) TDD 1-800-628-3323 (hearing impaired only) Quality Management Programs We have a comprehensive quality measurement and improvement strategy, and do not view it as an isolated, departmental function. Rather, we integrate quality management and metrics into all that we do. For details on our program, goals and our progress on meeting those goals, go to www.aetna.com/members/ health_coverage/quality/quality.html. If you do not have Internet access and would like a hard copy of the information referenced here, please contact Member Services at the toll-free number on your ID card and request a copy. Privacy Notice 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 your physical or mental health or condition, the provision of health care to you, or payment for the provision of health care to you. 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 you. To request a printed 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 Legal Support Services Department 151 Farmington Avenue, W121 Hartford, CT 06156 You can also visit www.aetna.com and link directly to the Notice of Privacy Practices by selecting the "Privacy Notices" link at the bottom of the page. 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. Non-discrimination statement Aetna does not discriminate in providing access to health care services on the basis of race, disability, religion, sex, sexual orientation, health, ethnicity, creed, age or national origin. We are required to comply with Title VI of the Civil Rights Act of 1964, the Age Discrimination Act of 1975, the Americans with Disabilities Act, other laws applicable to recipients of federal funds, and all other applicable laws and rules. Use of Race, Ethnicity and Language Data Aetna members have the option to provide us with race/ ethnicity and preferred language information. This information is voluntary and confidential. We collect this information to identify, research, develop, implement and/or enhance initiatives to improve health care access, delivery and outcomes for diverse members, and otherwise improve services to our members. We will maintain www.aetna.com 13 administrative, technical and physical safeguards to protect information concerning member race, ethnicity and language preference from inappropriate access, use or disclosure. This data will be collected, used or disclosed only in accordance with Aetna policies and applicable state and federal requirements. It is not used to determine eligibility, rating or claim payment. For more information, please visit www.aetna.com. If you do not have Internet access and would like a hard copy of the information referenced here, please contact Member Services at the toll-free number on your ID card and request a copy. Member Participation We maintain a Membership Advisory Committee, approved by the Missouri Department of Insurance, to encourage members to participate in matters of our Policy and Operation. For more information or to submit any suggestions or comments to the Committee, please write to: Aetna Health Inc. Member Advisory Committee C/O Quality Manager Suite 200 1350 Elbridge Payne Rd. Chesterfield, MO 63017 14 Health Insurance Portability and Accountability Act The following information is provided to inform you of certain provisions contained in the Group Health Plan, and related procedures that may be utilized by you in accordance with Federal law. to verify your status. As a terminated member, you can request a certificate for up to 24 months following the date of your termination. As an active member, you can request a certificate at any time. To request a Certificate of Prior Health Coverage, please contact Member Services at the telephone number listed on your ID card. 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 to 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 to the other coverage). Notice Regarding Women's Health and Cancer Rights Act Under this health plan, coverage will be provided to a person who is receiving benefits for a medically necessary mastectomy and who elects breast reconstruction after the mastectomy for: 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 marriage, birth, adoption or placement for adoption. To request special enrollment or obtain more information, contact your benefits administrator. (1) reconstruction of the breast on which a mastectomy has been performed; (2) surgery and reconstruction of the other breast to produce a symmetrical appearance; (3) prostheses; and Request for Certificate of Creditable Coverage (4) treatment of physical complications of all stages of mastectomy, including lymphedemas. If you are a member of an insured plan sponsor or a member of a self-insured plan sponsor who have contracted with us to provide Certificates of Prior Health Coverage, you have the option to request a certificate. This coverage will be provided in consultation with the attending physician and the patient, and will be subject to the same annual deductibles and coinsurance provisions that apply for the mastectomy. This applies to you if you are a terminated member, or are a member who is currently active but would like a certificate If you have any questions about our coverage of mastectomies and reconstructive surgery, please contact the Member Services number on your ID card. Health benefits and health insurance plans are underwritten or administered by Aetna Life Insurance Company. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Information subject to change. Aetna is committed to Accreditation by the National Committee for Quality Assurance (NCQA) as a means