Member rights: Understanding your health benefits FAQs

Where can I find out what my coverage or copay will be for certain procedures?
You can find coverage and copay information in your Summary of Benefits booklet. Your copay amount may also be listed on your Member ID card. If you can't find what you need from either source, please contact Member Services at the toll-free number on your Member ID card or send an e-mail to Member Services.

Do I have coverage for pre-existing conditions?
In most Aetna plans, you will have coverage for pre-existing conditions. There are, however, some plans that exclude coverage for pre-existing condition provisions for enrollees age 19 or older. In these plans, you may not be covered for pre-existing conditions if you were without health coverage during the 90-day period before you became an Aetna member and are 19 or older. Please refer to your plan documents for specific information about whether your plan excludes coverage of pre-existing conditions.

Where can I get a summary of my benefits?
Most employers will give you a benefits booklet, which includes a summary of your benefits. You should contact your employer’s benefits office to request this information. For some plans, your Aetna NavigatorTM secure member website will allow you to view a Medical Benefits Summary and other plan documents online. You can find these materials listed under Benefits on your Aetna Navigator home page (if this option is available to you). If you have an individual (Aetna Advantage) policy, please call Member Services. Our customer service representatives can have a benefits summary sent to you.

What services require prior approval or a doctor’s referral?
For members with HMO or Elect Choice EPO plans:
All specialty services (for instance, specialist physicians, physical therapy, speech therapy) require referrals from your primary care doctor, except for ob/gyn care and some radiology or lab services. Prior approval by Aetna is not required for these types of services. All inpatient admissions and certain other services require approval of Aetna, except for normal maternity admissions and emergency care, which require notification only.

For members with QPOS or Managed Choice POS plans:
To receive the higher benefit level under your plan of benefits, you should get a referral from your primary care doctor for all specialty services (except for programs such as ob/gyn, lab and X-ray). Prior approval by Aetna is not required for referrals. You may also visit any recognized provider, without a referral, but, your benefit will be at a reduced level.

All inpatient admissions and certain other services require prior approval, except for normal maternity admissions and emergency care, which require notification only.

For members with Open Access HMO, Open Access Elect Choice EPO, Open Access Managed Choice POS plans:
No referrals are required. You may seek specialty care from any provider within the network. All inpatient admissions and certain other services require prior approval from Aetna, except for normal maternity admissions and emergency care, which require notification only.

For members with Open Choice PPO, Traditional Choice plans:
No referrals are required. All inpatient admissions and certain other services require prior approval from Aetna, except for normal maternity admissions and emergency care, which require notification only.

How do I get prior approval or a referral? 
For members with HMO, Elect Choice EPO plans:
You should contact your primary care doctor to obtain prior approval or a referral. Prior approval by Aetna is not required for referrals. Your doctor is responsible for obtaining approval for inpatient admissions and certain other services.

For members with Open Access HMO, Open Access Elect Choice EPO plans:
No referrals are required. You may seek specialty care from any provider within the network. Your doctor is responsible for obtaining approval for inpatient admissions and certain other services.

For members with QPOS, USAccess, Managed Choice POS plans:
You may go directly to a specialist or facility without a referral, but you will receive a reduced level of benefit. You are responsible for contacting our Patient Management department to obtain approval for out-of-network hospital stays and certain other services. The only exception is for emergency care.

For members with Open Access Managed Choice POS, Open Choice PPO plans:
No referrals are required. You may seek care from any in-network or out-of-network providers. Your benefits will usually be less if you use an out-of-network provider except for out of network emergency care. Your doctor is responsible for obtaining approval for any in-network hospital stay. You are responsible for contacting our Patient Management department to obtain approval for out-of-network hospital stays and certain other services.

For members with Traditional Choice plans:
No referrals are required. You are responsible for obtaining approval for all hospital stays from our Patient Management department. The only exception is emergency care.

What if I don't get prior approval or a referral?

For members with HMO, Elect Choice EPO plans:
If you do not get a referral from your primary care doctor, you will be responsible for all payments associated with any services provided. Your doctor is responsible for obtaining any necessary prior approvals. The only exceptions are for emergency or urgent out-of-area care.

For members with QPOS or Managed Choice POS plans:
Aetna’s negotiated rates with participating providers will still apply to hospital and/or specialist services; however, your copay amount will be affected if you do not get a referral for specialist services. Participating physicians are required by contract to obtain approval for hospital services (also known as precertification) for you and they may be penalized if they fail to comply. We will not penalize you if a doctor fails to obtain precertification. You must get prior approval for out-of-network admissions, except for normal maternity admissions and emergency services, which require notification only. If you do not get prior approval, a penalty will be applied to your eligible charges.

For members with Open Access HMO, Open Access Elect Choice EPO plans:
Referrals are not required. You may seek specialty care from any provider within the network. Your doctor is responsible for obtaining prior approval for all inpatient hospital stays, except for normal maternity admissions and emergency services, which require notification only. We will not penalize you if a doctor fails to get prior approval.

For members with Open Access Managed Choice POS, Open Choice PPO plans:
Referrals are not required. You have direct access to specialty care. In network, your doctor must obtain prior approval for all inpatient hospital stays, except for normal maternity admissions and emergency services, which require notification only. You are responsible for obtaining prior approval for all out-of-network hospital stays, except for normal maternity admissions, which require notification only. If you do not get prior approval, a penalty will be applied to your eligible charges.

For members with Traditional Choice plans:
Referrals are not required. You have direct access to specialty care. You are responsible for obtaining prior approval for all inpatient hospital stays, except for normal maternity admissions and emergency services, which require notification only. If you do not get prior approval, a penalty will be applied to your eligible charges.

When do I need a referral from my PCP? 
For members with HMO, Elect Choice EPO plans:
You must get a referral for any specialty services (for instance, specialist physicians, physical therapy, speech therapy) not performed by your primary care doctor, except for direct access programs such as ob/gyn visits.

For members with QPOS or Managed Choice POS plans:
You must get a referral for any services not performed by your primary care doctor, except for direct access programs such as ob/gyn visits. You also have the option to seek care directly from non-participating providers for covered benefits, subject to deductible and coinsurance, as well as any amounts in excess of Aetna’s allowed amount for the services up to the provider’s billed charges.

For members with Open Access HMO, Open Access Elect Choice EPO, Open Access Managed Choice POS plans:
Referrals are not required within our network. You have direct access to specialty care from network providers.

For members with Open Choice PPO plans:
Referrals are not required. You have direct access to specialty care from network providers.

Can I get claim forms from this site?
Please contact your employer's benefits office for the insurance claim forms you need. If your benefits office does not have these forms, they can get more copies from their Aetna account representative.

How do I file a claim?
For members with HMO, Open Access HMO, Elect Choice EPO, Open Access Elect Choice EPO plans:

In most cases, you do not need to file claims – unless you have paid for emergency or out-of-area urgent care. However, if you receive a bill from a provider, or have paid for services that should have been covered under your plan, such as out of area emergency services, you should mail it with your ID number to the address shown on your ID card.

For members with QPOS, Managed Choice POS, Open Access Managed Choice POS, Open Choice PPO plans:
You do not need to file claims for in-network services. However, you must submit a claim form for out-of-network claims. We will send you a new claim form with each Explanation of Benefits (EOB).

For members with Traditional Choice plans:
You must submit a claim form. We will send you a new claim form with each Explanation of Benefits (EOB).

How long do I have to file a claim?
We expect you and your doctors to report all claims promptly. There are, however, some differences based on your specific plan.

For members with HMO, Open Access HMO, Elect Choice EPO, Open Access Elect Choice EPO, QPOS plans:
We allow your doctor 90 (unless state law or some other exception applies) days from the date-of-service to submit a claim for payment. We allow hospitals one year (unless state law or some other exception applies) from date-of-service to submit a claim for payment.

For members with Managed Choice POS, Open Access Managed Choice POS, Open Choice PPO, Traditional Choice plans:
We encourage claim filing for any benefits within 90 days from the date-of-service.
 
I am a new Aetna member. Before receiving my ID card, I needed to go to the doctor. My doctor then required that I pay for this service. Where should I send my claim for reimbursement? 
If you have received your medical ID card -- you can submit this claim (along with a completed Medical Benefits Request Form) to the address printed on your card. Note: You will find the Medical Benefits Request Form in the Forms Library at Aetna Navigator. Please include your member ID number, which appears on your card, and a copy of your doctor’s bill. Be sure that your payment to the doctor is clearly indicated on this bill.

If you do not have an ID card yet -- just log in to Aetna Navigator to view your Temporary Member Identification. You can use this information to submit your claim for reimbursement.
If you do not have Internet access -- please contact your employer’s benefits office. Your employer can give you a Medical Benefits Request Form, along with the mailing address to submit this form and/or your Member Services toll-free telephone number.

What if a primary care physician (PCP) cannot see me right away?
We encourage all doctors to schedule appointments with their patients in a timely manner. Our standard waiting times for appointments with a PCP or a specialist doctor are: 

  • Emergency: Immediately or your doctor should refer you to an emergency room (as appropriate) 
  • Urgent: The same day or within 24 hours
  • Non-urgent: Within three days 
  • Symptomatic: Within seven days
  • Preventive routine care: Within four weeks
  • Follow-up visit: Within two weeks

These standards are reviewed with physicians at the time of credentialing and recredentialing.

What is the difference between deductibles and copayments?
A deductible is the amount of covered medical expenses you’ll pay out of your own pocket each calendar year before benefits begin to be paid by your Aetna plan. Your deductible only applies to certain expenses. A copayment is the fee charged to you for a covered medical expense or for a covered prescription drug expense.

How does my out-of-pocket maximum work?
An out-of-pocket maximum is the total amount you’ll need to pay on your own before your Aetna plan benefits are paid in full. Once you’ve met the out-of-pocket maximum for a calendar year, your Aetna plan will then pay your covered expenses in full.

A provider has billed me; how do I know how much of the bill to pay?
For members with HMO, Open Access HMO, Elect Choice EPO, Open Access Elect Choice EPO plans:

For in-network claims, you are responsible for the copayment (a fixed amount or a percentage copayment) only.
Our contracts with network physicians require that they accept our payment, plus your benefit plan copayment, or percentage copayment, as payment in full. Our network physicians are instructed to collect the copayment amount listed on your ID card. Any provider reimbursement for services will not include this copayment amount. Network providers are not allowed to balance bill you for costs over the contracted rate.  Out of network providers may bill you for costs above our payment.  In the case of out of network emergency services, however, the plan will make you whole for covered expenses, except for your cost share .  You should submit a claim for any balance billing amount for out of network emergency services. You can submit a claim by sending the balance due bill with your Member ID to the address shown on your ID Card.

For members with QPOS, Managed Choice POS, Open Access Managed Choice POS, Open Choice PPO plans:
For in-network claims, you are responsible for the copayment only.
Our contracts with network physicians require that they accept our payment, plus your benefit plan copayment, or copayment percentage, as payment in full. Our network physicians are instructed to collect the copayment amount listed on your ID card. Any provider reimbursement for services will not include this copayment amount. We do not allow participating providers to engage in balance billing for costs over the contracted rate.

For out-of-network claims, you may be subject to deductibles and coinsurance. You may call the toll-free Member Services number listed on your ID card to confirm the amount you’ll need to pay. You are also responsible for any costs billed by the provider over the amount determined by Aetna to be the allowed amount under your plan.  In the case of out of network emergency services, however, the plan will make you whole for covered expenses, except for your cost share .  You should submit a claim for any balance billing amount for out of network emergency services. You can submit a claim by sending the balance due bill with your Member ID to the address shown on your ID Card.

For members with Traditional Choice plans:
Doctors, hospitals and other providers are not required to send bills for your health care to directly Aetna. As a result, you are responsible for the full amount of your bill and then submit a claim form to Aetna for appropriate reimbursement. Reimbursement will not include coinsurance or applicable deductibles, and will be limited the amount determined by Aetna to be the allowed amount under your plan.  In the case of out of network emergency services, however, the plan will make you whole for covered expenses, except for your cost share.  You should submit a claim for any balance billing amount for out of network emergency services. You can submit a claim by sending the balance due bill with your Member ID to the address shown on your ID Card.

How can I check the status of my claim? 
Your secure member website, Aetna Navigator®, provides online access to claim status, details and Explanation of Benefits for you and your family.  Or just call our customer service professionals using the toll-free number listed on your ID card.

What is Coordination of Benefits (COB)?
Coordination of benefits is process to determine which plan has responsibility for payment when you are covered by more than one health plan. Here’s how it works. Your primary plan is responsible for the initial payment of a claim. Your secondary plan may be responsible for an additional payment after the primary plan has paid its required amount. All provisions of your secondary plan would still apply, such as precertification and referral requirements. If these are not met, your secondary carrier may not make a payment, and you may be billed for the balance. Please note that the total amount of your health plan coverage would not be increased by Coordination of Benefits. Under this system, payment for your covered expenses is simply shared between two different health plans.

Why did I receive a Coordination of Benefits questionnaire and do I have to return it?
The Coordination of Benefits questionnaire helps us gather important information about your health plan coverage. We ask that you return your completed questionnaire to us as soon as possible. By returning your completed form, you can help us to decide which of your health plans has the main responsibility for paying your claim. This way, we can make the correct claim payment and avoid duplicate payments.

What should I do with a medical bill for care I received outside the U.S.?
With most foreign claims, you’ll need to pay for medical services yourself. You can then submit your foreign bill to Aetna for reimbursement. If you are receiving services coordinated through our National Medical Excellence Program®, we will handle your overseas claims like any other claim. We will translate your claim and determine the daily rate of exchange between the US dollar and a foreign currency. After this, we will mail our payment (with an Explanation Of Benefits) to the appropriate overseas address.

What is the procedure for making a complaint against a doctor or other provider?
We have formal and informal ways for you to give us concerns about quality of care. You can raise issues to us by calling a customer service professional at our toll-free number (Please see your ID card). You can also submit a complaint in writing or Contact Us to submit the complaint electronically. Your complaint will be entered into our tracking system and followed up in the same way as calls to our toll-free number.

We encourage you to have direct discussions with your treating physician. Our experience has shown that complaints are less frequent when there is open communication between doctors and their patients.

How do I appeal a certification or authorization denial?
Our grievance and appeals process is outlined in the Member Rights area of Aetna.com.

How do I appeal a claim payment or denial? 
You can find detailed information about appealing a claim payment or denial in the Health Insurance and Appeals Process section for PPO and HMO members. 

What if waiting for you to decide on my appeal would harm my health?
You should always seek care promptly in any emergency. We do not require prior approval for emergency services, and physicians and hospitals should not withhold care in these circumstances. We do provide expedited appeals for urgent, non-emergency services. These expedited appeals are usually reviewed within four to eight hours after they are received. At the latest, these expedited appeals are reviewed no more than one business day after we have received the information needed to conduct this review. Benefits for an ongoing course of treatment will not be reduced or terminated without advance notice and an opportunity for advance review.

My Explanation of Benefits says I received services that I did not have. What should I do?
You should call the toll-free member services number on your ID card. We will review your Explanation of Benefits to determine how an error occurred.

Does Aetna cover vision care? 
Yes, you can generally visit a participating optometrist or ophthalmologist for a routine eye exam without a referral (subject to the benefit schedule below). Plan features and availability may vary by location and are subject to change. You will usually need to make a copayment for an eye exam. If you wear eyeglasses or contact lenses, our typical benefit schedule allows eye exams as follows: 

  • Members age 1 through 18 – once every 12-month period 
  • Members age 19 and over – once every 24-month period

If you do not wear glasses or contact lenses, our benefit schedule typically allows eye exams once every 24-month period.

If you need a vision exam other than a routine exam, please consult your primary care doctor, who can refer you to a participating eye doctor for evaluation and treatment.

Eyeglasses and Contact Lenses
As an Aetna member, you can receive substantial discounts on eyeglasses, contact lenses and nonprescription items such as sunglasses and contact lens solutions through the Vision One® discount program at thousands of locations across the country. Your medical plan may also include an allowance for prescription glasses or contact lenses. See your Certificate of Coverage for details.

Does Aetna cover flu shots? 
Yes, Aetna covers flu shots for young children, teens and adults.

How can I get information regarding the Fitness Program that is offered to Aetna Members (i.e., health clubs and gyms)? 
Please contact Member Services at the toll-free number listed on your ID card. If you do not have an ID card yet, you can get this toll-free number from your employer's benefits office. Member Services will send you information about our Fitness Program including a program description, a list of participating health clubs in your area, and a list of home exercise equipment available for purchase.

Am I covered when I am outside my "home" service area? 
HMO, QPOS®, and Managed Choice® plan members, including insured students away at school, are covered for emergency and urgent care when outside their normal "home" service area*. Please see our Emergency Care FAQ section for a description of what we consider to be an emergency. Emergency and Urgent care may be obtained from a physician, a walk-in clinic, an urgent care center or an emergency facility.

Although you are outside your "home" service area, you will still need to coordinate your care through your Primary Care Physician (PCP). In case of an accidental injury or life-threatening medical emergency where you are admitted to an inpatient facility, you (or someone on your behalf) should immediately notify your PCP. In other cases, your PCP should be contacted within 48 hours of the emergency.

How long can my children remain covered? 
Your children are covered until age 26, however, some States require that dependent children remain covered beyond age 26. Employers may choose to extend coverage for full-time students beyond age 26. Please check with your employer, or see your plan documents, for more details.

How long can my child be covered if he or she has disabilities? 
Coverage for an incapacitated child can continue after age 26 as long as he or she meets the handicapped child requirements specified in the plan of benefits selected by your employer.
HMO, Open Access HMO, QPOS:
In most cases, your dependent child must become incapacitated prior to the limiting age. This limiting age is determined by your employer’s age limit for dependents. To provide coverage for an incapacitated child beyond age 26, we request a letter from your child’s family physician providing the information needed to establish that he or she meets the necessary requirements. This letter is then forwarded to our medical director for approval.

Elect Choice EPO, Open Access Elect Choice EPO, Managed Choice POS, Open Access Managed Choice POS, Open Choice PPO, Traditional Choice:
You should first complete a continuation of coverage form to request coverage for your incapacitated child beyond age 26. This form must be accompanied by an attending physician's statement of mental or physical handicap. Both forms should then be submitted to your employer for review and signature before forwarding to our claim office.

We will review the forms and approve or deny your application. At this point, we will record the decision in our claim system and notify your employer. If approved, your coverage will be reviewed again two years after initial approval or as necessary based on the outcome of the initial review. Depending on the circumstances and the dependent child's potential for rehabilitation, we may exercise our right to require proof of continued incapacity once a year. We may also seek an examination of the dependent child as often as reasonable and necessary to resolve questions about his or her incapacity.

How do I order additional ID cards?
You can order an ID card by calling the toll-free member services number on your ID card or by visiting our Aetna NavigatorTM website.

Do I need to carry my ID card with me at all times?
Yes, you should always keep your ID card with you.

What happens to my coverage if I quit my job or I'm laid off or fired?
Please contact your former employer's benefits office and if you want continuation of coverage tell them you're interested in purchasing a COBRA policy. According to Federal law, your company must tell you about your options for purchasing this coverage.

What happens to my coverage if I move out of the area? 
For HMO, Open Access HMO, QPOS, Elect Choice EPO, Open Access Elect Choice EPO, Managed Choice POS, Open Access Managed Choice POS, Open Choice PPO, it depends on the plan selected by the employer. Your employer may choose to purchase an out-of-area plan for members who reside outside of our service areas.

For Traditional Choice, there would be no impact on coverage.

What happens to my coverage if I turn 65? 
Generally, if you are age 65 or older and still working, there would be no change to your coverage.  Once you become eligible for Medicare, you may convert your coverage to our Golden Medicare Plan (if it is available to you).

What happens to my coverage if I retire? 
Once you retire, your options will depend on the plan and benefits offered by your employer:

  • You may be able to remain under your regular plan. When you become eligible for Medicare, we would coordinate your benefits with Medicare. 
  • If your employer offers a separate retiree plan, you could join that plan.
  • If your employer does not offer a retiree plan, or does not allow retirees to maintain coverage under its plan for active employees, you could then be eligible for Medicare (if you meet the age requirement). 
  • If you are not eligible for any of these options, you can use COBRA coverage until you become eligible for Medicare. In addition, you could purchase an individual policy and use this coverage until you are eligible for Medicare.

What if I become disabled? 
If you become disabled, we will continue to provide you with health coverage – as long as you still meet the eligibility rules set by your employer. Assuming that your employer keeps you on the same health plan (and continues to pay premiums), you would qualify for standard benefits as described in your plan documents. The length of the extension of benefits is determined by the plan selected by the employer. Once the extension of benefits has expired, the member is eligible to apply for COBRA coverage.

What if my spouse and I divorce? 
If your spouse will no longer be covered under this plan, either you or your employer should send us a change request. A former spouse can still be covered (usually under COBRA or through an individual policy) if required by a divorce decree. This requirement varies by state.

What routine coverage do I have while I am traveling?
HMO, Open Access HMO Elect Choice EPO, Open Access Elect Choice EPO:

For routine medical treatment, you are required to obtain services from network providers. You are covered only for emergency and urgent care once you travel outside the service area.

QPOS:
For routine medical treatment, you are responsible for contacting your PCP for a referral to a physician. A copay will apply. You may also access nonparticipating providers at the non-referred benefit level, subject to deductible and coinsurance.

Managed Choice POS, Open Access Managed Choice POS:
You have access to preferred-level benefits from any participating provider in any of our networks across the country. The plan would be administered based on the plan design of your home network. If you are traveling, please call the member services number on your ID card or use DocFind®, to find a participating provider in your location. You should call your PCP for a referral in non-emergency situations. You also have access to non-participating providers at the non-preferred benefit level. You will be covered for out of network emergency care at the preferred level.

Open Choice PPO:
You have access to preferred-level benefits from any participating provider in any of our networks across the country. The plan would be administered based on the plan design of your home network. If you are traveling, please call the member services number on your ID card or use DocFind®, to find a participating provider in your location. You also may access non-participating providers at the non-preferred benefit level. You will be covered for out of network emergency care at the preferred level.

Traditional Choice: You may access routine care through any recognized provider.

What emergency coverage do I have while I am traveling?
We cover emergency care 24 hours a day, 7 days a week – anywhere in the world. Generally speaking, an emergency is a situation when you could reasonably expect that the absence of immediate medical attention would result in serious jeopardy to your health, or if you are a pregnant woman, to the health of your unborn child. This definition may vary based on state regulations.

When does coverage begin?
As a new employee, you are eligible for medical coverage on the date you are hired. You have 31 days from that date to complete your enrollment process. Your coverage takes effect after we receive your completed enrollment information.

To enroll newborns or adopted children, we must receive your request within 31 days after the date of birth or adoption. On late enrollment requests, if adding a newborn or adopted child would have generated no additional premium at the time, the effective date is the date of birth or adoption.

*If you are enrolled in an Open Choice PPO, you do not need a referral to see a participating provider when outside your home network.

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