Section 1. How This Plan Works
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory or visit our website at www.aetnafeds.com.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan’s benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.
OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Aetna holds the following accreditations: National Committee for Quality Assurance and/or the local plans and vendors that support Aetna hold accreditation from the National Committee for Quality Assurance. To learn more about this plan’s accreditation(s), please visit the following website:
General features of our High Option
- You can see participating network specialists without a referral (Open Access).
- You can choose between our Basic Dental or Dental PPO option. Under Basic Dental, you can access preventive care for a $5 copay and other services at a reduced fee. Under the PPO option, if you see an in-network dentist, you pay nothing for preventive care after a $20 annual deductible per member. You may also utilize non-network dentists for preventive care, but at reduced benefit levels after satisfying the $20 annual deductible per member. You pay all charges for other services when utilizing non-network dentists.
- You receive a $100 reimbursement every 24 months for glasses or contact lenses.
We have Open Access benefits
- Does not apply to members in the state of California (Enrollment Code 2X).
Members in the state of California must continue to obtain referrals from their PCPs to access specialist care. If your primary care provider (PCP) is part of an IPA, you must be referred to specialists within or approved by that IPA.
Our HMO offers Open Access benefits. This means you can receive covered services from a participating network specialist without a required referral from your primary care provider or by another participating provider in the network.
This Open Access Plan is available to members in our FEHBP service area. If you live or work in an Open Access HMO service area, you can go directly to any network specialist for covered services without a referral from your primary care provider. Note: Whether your covered services are provided by your selected primary care provider (for your PCP copay) or by another participating provider in the network (for the specialist copay), you will be responsible for payment which may be in the form of a copay (flat dollar amount) or coinsurance (a percentage of covered expenses). While not required, it is highly recommended that you still select a PCP and notify Member Services of your selection at 800-537-9384. If you go directly to a specialist, you are responsible for verifying that the specialist is participating in our Plan. If your participating specialist refers you to another provider, you are responsible for verifying that the other specialist is participating in our Plan.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles and non-covered services and supplies).
This is a direct contract prepayment Plan, which means that participating providers are neither agents nor employees of the Plan; rather, they are independent doctors and providers who practice in their own offices or facilities. The Plan arranges with licensed providers and hospitals to provide medical services for both the prevention of disease and the treatment of illness and injury for benefits covered under the Plan.
Specialists, hospitals, primary care providers and other providers in the Aetna network have agreed to be compensated in various ways:
- Per individual service (fee-for-service at contracted rates),
- Per hospital day (per diem contracted rates),
- Under capitation methods (a certain amount per member, per month), and
- By Integrated Delivery Systems (“IDS”), Independent Practice Associations (“IPAs”), Physician Medical Groups (“PMGs”), Physician Hospital Organizations (“PHOs”), behavioral health organizations and similar provider organizations or groups that are paid by Aetna; the organization or group pays the physician or facility directly. In such arrangements, that group or organization has a financial incentive to control the costs of providing 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. You are encouraged to ask your physicians and other providers how they are compensated for their services.
Your rights and responsibilities
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers. OPM’s FEHB website (www.opm.gov/insure) lists the specific types of information that we must make available to you. Some of the required information is listed below.
- Aetna has been in existence since 1850
- Aetna is a for-profit organization
You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our website, www.aetnafeds.com. You can also contact us to request that we mail a copy to you.
If you want more information about us, call 800-537-9384 or write to Aetna at P.O. Box 550, Blue Bell, PA 19422-0550. You may also visit our website at www.aetnafeds.com.
By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website at www.aetnafeds.com to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.
Your medical and claims records are confidential
We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.
Medical Necessity
“Medical necessity” 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:
- In accordance with generally accepted standards of medical practice; and,
- 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,
- 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.
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.
Direct Access Ob/Gyn Program
This program allows female members to visit any participating gynecologist for a routine well-woman exam, including a Pap smear, one visit per calendar year. The program also allows female members to visit any participating gynecologist for gynecologic problems. Gynecologists may also refer a woman directly to other participating providers for specialized covered 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, the IDS, or similar organization and the organization may have different referral policies.
Mental Health/Substance Use
Behavioral health services (e.g. treatment or care for mental disease or illness, alcohol abuse and/or substance misuse) are managed by Aetna Behavioral Health. We also make initial coverage determinations and coordinate referrals, if required; any behavioral health care referrals will generally be made to providers affiliated with the organization, unless your needs for covered services extend beyond the capability of these providers. As with other coverage determinations, you may appeal behavioral health care coverage decisions in accordance with the terms of your health plan.
Ongoing Reviews
We conduct ongoing reviews of those services and supplies which are recommended or provided by health professionals to determine whether such services and supplies are covered benefits under this Plan. If we determine that the recommended services and supplies are not covered benefits, you will be notified. If you wish to appeal such determination, you may then contact us to seek a review of the determination.
Authorization
Certain services and supplies under this Plan may require authorization by us to determine if they are covered benefits under this Plan. See section 3, "You need prior plan approval for certain services."
Patient Management
We have developed a patient management program to assist in determining what health care services are covered and payable under the health plan and the extent of such coverage and payment. The program assists members in receiving appropriate health care and maximizing coverage for those health care services.
Where such use is appropriate, our utilization review/patient management staff uses nationally recognized guidelines and resources, such as Milliman Care Guidelines© and InterQual® ISD criteria, to guide the precertification, concurrent review and retrospective review processes. To the extent certain utilization review/patient management functions are delegated to integrated delivery systems, independent practice associations or other provider groups (“Delegates”), such Delegates utilize criteria that they deem appropriate.
Term | Definition |
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Precertification is the process of collecting information prior to inpatient admissions and performance of selected ambulatory procedures and services. The process permits advance eligibility verification, determination of coverage, and communication with the physician and/or you. It also allows Aetna to coordinate your transition from the inpatient setting to the next level of care (discharge planning), or to register you for specialized programs like disease management, case management, or our prenatal program. In some instances, precertification is used to inform physicians, members and other health care providers about cost-effective programs and alternative therapies and treatments. Certain health care services, such as hospitalization or outpatient surgery, require precertification with Aetna to ensure coverage for those services. When you are to obtain services requiring precertification through a participating provider, this provider should precertify those services prior to treatment. |
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| The concurrent review process assesses the necessity for continued stay, level of care, and quality of care for members receiving inpatient services. All inpatient services extending beyond the initial certification period will require concurrent review. |
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| 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. |
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Retrospective Record Review
| The purpose of retrospective record review is to retrospectively analyze potential quality and utilization issues, initiate appropriate follow-up action based on quality or utilization issues, and review all appeals of inpatient concurrent review decisions for coverage and payment of health care services. 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. |
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Member Services
Representatives from Member Services are trained to answer your questions and to assist you in using the Aetna Plan properly and efficiently. After you receive your ID card, you can call the Member Services toll-free number on the card when you need to:
- Ask questions about benefits and coverage.
- Notify us of changes in your name, address or phone number.
- Change your primary care provider or office.
- Obtain information about how to file a grievance or an appeal.
Privacy Notice
How we guard your privacy - We’re committed to keeping your personal information safe
What personal information is and what it isn’t - By “personal information,” we mean that which can identify you. It can include financial and health information. It doesn’t include what the public can easily see. For example, anyone can look at what your plan covers.
How we get information about you - We get information about you from many sources, including from you. But we also get information from your employer, other insurers, or health care providers like doctors.
When information is wrong - Do you think there’s something wrong or missing in your personal information? You can ask us to change it. The law says we must do this in a timely way. If we disagree with your change, you can file an appeal. Information on how to file an appeal is on our member website. Or you can call the toll-free number on your ID card.
How we use this information - When the law allows us, we use your personal information both inside and outside our company. The law says we don’t need to get your permission when we do.
We may use it for your health care or use it to run our plans. We also may use your information when we pay claims or work with other insurers to pay claims. We may use it to make plan decisions, to do audits, or to study the quality of our work.
We may use or share your protected health information (PHI):
- With the U.S. Office of Personnel Management (OPM)
- With your employing agency in connection with payment or health care operations
- When required by federal law
We’re also required to share your PHI to OPM for its claims data warehouse. The data is used for its Federal Employees Health Benefits (FEHB) Program.
This means we may share your information with doctors, dentists, pharmacies, hospitals or other caregivers. We also may share it with other insurers, vendors, government offices, or third-party administrators. But by law, all these parties must keep your information private.
When we need your permission - There are times when we do need your permission to disclose personal information.
This is explained in our Notice of Privacy Practices. This notice clarifies how we use or disclose your Protected Health Information (PHI):
- For workers’ compensation purposes
- As required by law
- About people who have died
- For organ donation
- To fulfill our obligations for individual access and HIPAA compliance and enforcement
To get a copy of this notice, just visit our member website. Or call the toll-free number on your ID card.
If you want more information about us, call 800-537-9384, or write to Aetna, Federal Plans, PO Box 550, Blue Bell, PA 19422-0550. You may also contact us by fax at 860-975-1669 or visit our website at www.aetnafeds.com.
Aetna HMO Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is:
California, Los Angeles & San Diego areas – Enrollment code 2X – Los Angeles, Orange, San Diego, San Luis Obispo, Santa Barbara and Ventura counties, and portions of Kern, Riverside and San Bernardino counties as defined below:
Kern County: All towns except Cantil, China Lake, Garlock, Johannesburg, Mojave and Ridgecrest
Riverside County: All towns except Blythe, Desert Center and Mesa Verde
San Bernardino County: All towns except Baker, Big River, Cadiz, Cima, Danby, Earp, Essex, Ivonpah, Kelso, Lake Havasu, Needles, Nipton, Parker Dam, Rice and Vidal.
Aetna Open Access Service Area
The following service areas will be for our Aetna Open Access HMO. Under these plans, members may see network specialists without obtaining a referral from their primary care provider (PCP). To enroll in this Plan, you must live in or work in our service area. You are required to receive services from our network of providers. There are no out-of-network benefits. This is where our providers practice. Our service area is:
Arizona, Phoenix and Tucson areas– Enrollment code WQ – Cochise, Graham, Gila, Maricopa, Mohave, Pima, Santa Cruz, Yavapai and Yuma counties and portions of the following county as defined by the towns below:
Pinal: Apache Junction, Casa Grande, Coolidge, Eloy, Florence, Kearny, Maricopa, Picacho, Queen Creek, Red Rock, Sacaton, Stanfield and Superior.
Georgia, Athens and Atlanta areas – Enrollment code 2U – Barrow, Bartow, Butts, Carroll, Cherokee, Clarke, Clayton, Cobb, Coweta, Dawson, DeKalb, Douglas, Fayette, Floyd, Forsyth, Fulton, Gordon, Greene, Gwinnett, Hall, Heard, Henry, Jackson, Jasper, Lamar, Morgan, Newton, Oconee, Oglethorpe, Paulding, Pickens, Pike, Polk, Rockdale, Spalding and Walton counties.
Pennsylvania, Pittsburgh and Western PA areas– Enrollment code YE – Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Indiana, Jefferson, Lawrence, Mckean, Mercer, Potter, Somerset, Venango, Warren, Washington and Westmoreland counties.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency or urgent care benefits. We will not pay for any other health care services out of our service area unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), they will be able to access full HMO benefits if they reside in any Aetna HMO service area by selecting a PCP in that service area. If not, you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.