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Understanding Your Health Plan Benefits

  1. Where can I find out what my coverage or co-pay will be for certain procedures?
  2. Do I have coverage for pre-existing conditions?
  3. Where can I get a summary of my benefits?
  4. What services require prior approval or a referral?
  5. How do I get prior approval or a referral?
  6. What if I don't get prior approval or a referral?
  7. When do I need a referral from my PCP?
  8. Can I get claim forms from this site?
  9. How do I file a claim?
  10. How long do I have to file a claim?
  11. I am a new Aetna member and needed to go to the doctor before I received my ID card, so the physician required that I pay for the service. Where do I send the claim and how do I get reimbursed?
  12. What if a primary care physician cannot see me right away?
  13. What is the difference between deductibles and copayments?
  14. How does my out-of-pocket maximum work?
  15. A provider has billed me; how do I know how much of the bill to pay?
  16. How can I check the status of my claim?
  17. What is Coordination of Benefits (COB?)
  18. Why did I receive a Coordination of Benefit questionnaire and do I have to return it?
  19. What do I do with a foreign medical bill for care I received outside of the U.S.?
  20. What is the procedure for lodging a complaint against a provider?
  21. How do I appeal a certification or authorization denial?
  22. How do I appeal a claim payment or denial?
  23. What if waiting for you to decide on my appeal would harm my health?
  24. My Explanation of Benefits says I received services that I did not have. What should I do?
  25. Where can I find information about preventive care?
  26. Does Aetna cover vision care?
  27. Does Aetna cover flu shots?
  28. How can I get information regarding the Fitness Program that is offered to Aetna Members (i.e., health clubs and gyms)?
  29. Am I covered when I am outside my "home" service area?
  30. Is my child covered while in college?
  31. Can I cover a dependent who lives out-of-state or my child away at school?
  32. How long can my children remain covered?
  33. How long can my child be covered if he or she has disabilities?
  34. How do I order additional ID cards?
  35. Do I need to carry my ID card with me at all times?
  36. What happens to my coverage if I quit my job or I'm laid off or fired?
  37. What happens to my coverage if I move out of the area?
  38. What happens to my coverage if I turn 65?
  39. What happens to my coverage if I retire?
  40. What if I become disabled?
  41. What if my spouse and I divorce?
  42. What do I do if I need care while traveling?
  43. What routine coverage do I have while I am traveling?
  44. What emergency coverage do I have while I am traveling?
  45. How can I get information about Alternative Health Care Programs?
  46. What are pre-existing conditions and how do they impact coverage?
  47. When does coverage begin?
  1. Where can I find out what my coverage or co-pay will be for certain procedures?
    Please refer to your Summary of Benefits booklet. Your co-pay amount may also be listed on your Member ID card. If you can't find the data you need in either location, please contact Member Services at the toll-free number on your Member ID card or send an e-mail to Member Services.

  2. Do I have coverage for pre-existing conditions?
    For HMO, Open Access HMO, QPOS, USAccess, in most plans, there are no exclusions for pre-existing conditions. However, please refer to your plan documents because some plans may contain a pre-existing conditions clause.

    For Elect Choice EPO, Open Access Elect Choice EPO, Managed Choice POS, Open Access Managed Choice POS, Open Choice PPO, Traditional Choice, pre-existing condition provisions apply according to the plan design the employer chooses, but only if the newly eligible individual had no creditable coverage in the 90-day period prior to the effective date.

  3. Where can I get a summary of my benefits?
    Most employers distribute a benefit booklet directly to their employees. Please contact your employer's benefits office to request this information.

  4. What services require prior approval or a referral?

    HMO, Elect Choice EPO:
    All specialty services require referrals, except for direct access programs such as ob/gyn. Prior approval by Aetna is not required for referrals. All inpatient admissions and certain other services require approval excluding normal maternity admissions, which require notification only. Participating physicians are responsible for obtaining precertification/prior approval.

    QPOS, USAccess, Managed Choice POS:
    To receive the higher benefit level under the plan of benefits selected by the Employer, members should obtain a referral from their PCP for all specialty services except direct access programs such as ob/gyn, lab and X-ray. Prior approval by Aetna is not required for referrals. Members may also visit any recognized provider, without a referral, at a reduced benefit level.

    All inpatient admissions and certain other services require precertification/approval excluding normal maternity admission, which require notification only. Participating physicians are responsible for obtaining precertification/prior approval.

    Open Access HMO, Open Access Elect Choice EPO, Open Access Managed Choice POS:
    Referrals are not required. Members have direct access to specialty care within the network. All inpatient admissions and certain other services require prior precertification/approval excluding normal maternity admissions, which require notification only. Participating physicians are responsible for obtaining precertification/prior approval.

    Open Choice PPO, Traditional Choice:
    Referrals are not required. All inpatient admissions and certain other services require prior precertification/approval excluding normal maternity admissions, which require notification only. Participating physicians are responsible for obtaining precertification/prior approval.

  5. How do I get prior approval or a referral?

    HMO, Elect Choice EPO:
    Members are responsible for contacting their PCP for referrals. Prior approval by Aetna is not required for referrals. Participating physicians are responsible for obtaining precertification/prior approval for inpatient admissions and certain other services.

    Open Access HMO, Open Access Elect Choice EPO:
    Referrals are not required. Members have direct access to specialty care within the network. Participating physicians are responsible for obtaining precertification/prior approval for inpatient admissions and certain other services.

    QPOS, USAccess, Managed Choice POS:
    Members may self-refer to a specialist or facility and receive a reduced level of benefit. Members are responsible for contacting our Patient Management department to obtain approval/precertification of out-of-network hospital confinements and certain other services.

    Open Access Managed Choice POS, Open Choice PPO:
    Members may self-refer to in-network and out-of-network providers; therefore, referrals are not required. Participating physicians are responsible for obtaining approval/precertification of in-network hospital confinements. Members are responsible for contacting our Patient Management department to obtain approval/precertification of out-of-network hospital confinements and certain other services.

    Traditional Choice:
    Referrals are not required. Members are responsible for obtaining approval/precertification of all hospital confinements with our Patient Management department.

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

    HMO, Elect Choice EPO:
    The member is responsible for the payment(s) associated with the services provided if they do not obtain a prior referral from their PCP. The PCP is responsible for obtaining precertification. An exception is emergency or urgent out-of-area care.

    QPOS, USAccess, Managed Choice POS:
    Discounts from participating providers will still apply to hospital and/or specialist services; however, the member's copay differential will be affected if they self-refer. Participating physicians are contractually obligated to initiate precertification for the member and may be penalized if they fail to comply. We do not penalize the member when the physician fails to precertify. For out-of-network admissions and certain other services except normal maternity admissions, which require notification only, the member is responsible for precertification and if the member does not precertify, a penalty applies to eligible charges for failure to precertify.

    Open Access HMO, Open Access Elect Choice EPO:
    Referrals are not required. Members have direct access to specialty care in the network. The participating physician is responsible for precertifying all inpatient confinements and certain other services except normal maternity admissions, which require notification only. We do not penalize the member when the physician fails to precertify.

    Open Access Managed Choice POS, Open Choice PPO:
    Referrals are not required. Members have direct access to specialty care. In network, the attending physician is responsible for precertifying all inpatient confinements and certain other services except normal maternity admissions, which require notification only. The member is responsible for precertifying all out-of-network confinements and certain other services except normal maternity admissions, which require notification only. If the member does not precertify, a failure to precertify penalty applies to eligible charges.

    Traditional Choice:
    Referrals are not required. Members have direct access to specialty care. The member is responsible for precertifying all inpatient confinements and certain other services except normal maternity admissions, which require notification only. If the member does not precertify, a failure to precertify penalty applies to eligible charges.

  7. When do I need a referral from my PCP?

    HMO, Elect Choice EPO:
    A referral is needed for any services not performed by the PCP, except for direct access programs such as ob/gyn visits.

    QPOS, USAccess, Managed Choice POS:
    A referral is needed for any services not performed by the PCP, except for direct access programs such as ob/gyn visits. Members also have the option to self-refer directly to non-participating providers for covered benefits, subject to deductible and coinsurance. The benefits are the same, the out-of-pocket costs are higher.

    Open Access HMO, Open Access Elect Choice EPO, Open Access Managed Choice POS:
    Referrals are not required within the network. Members have direct access to specialty care.

    Open Choice PPO:
    Referrals are not required. Members have direct access to specialty care.

  8. Can I get claim forms from this site?
    Please contact your employer's benefits office for the insurance claim forms that you need. If they don't have any on hand, they can obtain them from their Aetna account representative.



  9. How do I file a claim?

    HMO, Open Access HMO, Elect Choice EPO, Open Access Elect Choice EPO
    Members generally do not need to file claims unless they 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, you should mail it with your ID number to the address shown on your ID card.

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

    Traditional Choice
    Members must submit a claim form. We send a new claim form with each Explanation of Benefits (EOB).

  10. How long do I have to file a claim?

    HMO, Open Access HMO, Elect Choice EPO, Open Access Elect Choice EPO
    We expect members and providers to report all claims promptly. We allow providers 90 days from the date-of-service to submit a claim for payment. We allow hospitals one year from date-of-service to submit a claim for payment.

    QPOS, USAccess
    We expect members and providers to report all claims promptly. We allow providers 90 days from the date-of-service to submit a claim for payment. We allow hospitals one year from date-of-service to submit a claim for payment.

    Managed Choice POS, Open Access Managed Choice POS, Open Choice PPO, Traditional Choice
    We expect members and providers to report all claims promptly. We encourage claim filing for any benefits within 90 days from the date-of-service. However, if through circumstances beyond your control you are unable to file within this time frame, we will currently accept and process claims for a period of up to two years from the date-of-service.

  11. I am a new Aetna member and needed to go to the doctor before I received my ID card, so the physician required that I pay for the service. Where do I send the claim and how do I get reimbursed?
    If you have received your medical ID Card, please submit your claim along with a completed "Medical Benefits Request Form" to the address printed on your card. Be sure to include your Member ID number and the employee's Social Security number (so we can identify your account). Also, please be sure that your payment to the provider is clearly indicated on the bill. Medical Benefit Request forms can be obtained from your employer's benefits office, or by calling your Member Services office at the toll-free number listed on your ID card. If you do not have an ID card yet, please contact your employer's benefits office to obtain this toll-free number.

    If you have not received your Medical ID card, please contact your employer's benefits office to obtain the mailing address to which to submit your claim form.



  12. What if a primary care physician cannot see me right away?
    Our standards for PCP and specialist appointment waiting times are as follows:

    • Emergency: Must be seen or referred to ER as appropriate
    • Urgent: 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 criteria are reviewed with physicians at the time of credentialing and recredentialing. If a member finds that a participating provider cannot meet these standards, they may contact member services at the toll-free number listed on the ID card.

  13. What is the difference between deductibles and copayments?
    A calendar year deductible is the amount of covered medical expenses the member pays each calendar year before benefits are paid by the plan. A copayment is the fee charged to a member for a covered medical expense or for a covered prescription drug expenses.

  14. How does my out-of-pocket maximum work?
    A plan may specify an out-of-pocket amount. Once the out-of-pocket maximum is met for the calendar year, the member is no longer responsible to pay coinsurance.

  15. A provider has billed me; how do I know how much of the bill to pay?

    HMO, Open Access HMO, Elect Choice EPO, Open Access Elect Choice EPO
    For in-network claims, members are responsible for the copayment only.

    Part of our contractual agreements with network physicians include the requirement that physicians accept our payment, plus the member's benefit plan copayment, or copayment percentage, as payment in full. Our physicians are instructed to collect the copayment amount listed on the member's ID card. Any provider reimbursement for services will be less the copayment amount. Balance billing for costs over the contracted rate is not permitted by participating providers.

    QPOS, USAccess, Managed Choice POS, Open Access Managed Choice POS, Open Choice PPO
    For in-network claims, members are responsible for the copayment only.

    Part of our contractual agreements with network physicians include the requirement that physicians accept our payment, plus the member's benefit plan copayment, or copayment percentage, as payment in full. Our physicians are instructed to collect the copayment amount listed on the member's ID card. Any provider reimbursement for services will be less the copayment amount. Balance billing for costs over the contracted rate is not permitted by participating providers.

    For out-of-network claims, members may be subject to deductibles and coinsurance. Members may call the toll-free member services number listed on their ID card to confirm what they need to pay. Members are also responsible for any costs billed by the provider over reasonable and customary charges.

    Traditional Choice
    Members pay the full amount of the bill and then submit a claim form to Aetna for appropriate reimbursement. Reimbursement will be less coinsurance, applicable deductibles and limited to reasonable and customary charges.

  16. How can I check the status of my claim?
    Members may call the toll-free number listed on their ID card. Customer service professionals will assist members with claim status inquiries.

    Throughout the year, we will be expanding our Aetna Navigator™ website that will enhance member service contact and help members better understand and use health care benefits. This initiative will enable members in some plans to access more of their health plan information, including claim status, online.

  17. What is Coordination of Benefits (COB)?
    Coordination of benefits is used when a member is covered by more than one health benefits plan. The primary plan is responsible for the initial payment of the claim. The secondary carrier may be responsible for payment after the primary health benefits plan has paid its contracted amount. All provisions of the secondary plan would still apply, such as precertification and referral requirements. If these are not met, the secondary carrier is not responsible for payment of the claim, and the member may be billed for the balance. The combined benefits will not be more than the expenses recognized under these plans.

  18. Why did I receive a Coordination of Benefit questionnaire and do I have to return it?
    Completion of the Coordination of benefits questionnaire is very important as it is our method of determining whether a member has any other coverage that might be primary in a given situation. A coordination of benefit questionnaire helps us to gather the information we need to determine the correct claim payment and avoid duplicate payments. We ask that members complete coordination of benefit questionnaires as soon as they receive them.

  19. What do I do with a foreign medical bill for care I received outside of the U.S.?
    We handle overseas claims like any other claim. The member must submit the claim using our standard claim form. We translate the claim and obtain the daily rate of exchange. The Explanation Of Benefits and member's payment are then mailed to the appropriate address.

  20. What is the procedure for lodging a complaint against a provider?
    There are both formal and informal ways for members to communicate their quality of care concerns. Many potential issues are resolved by calling a customer service professional at our toll-free number. In addition, members can submit a complaint in writing or Contact Us to submit the complaint electronically. The complaint is then entered into our tracking system and the process continues on the same basis as if it were received by telephone.

    We encourage direct discussions between treating physicians and our physician reviewers. Our experience has shown that complaints are less frequent when there is open communication.



  21. How do I appeal a certification or authorization denial?

    HMO, Open Access HMO, QPOS, USAccess
    Our grievance and appeals process is outlined below.

    Calling Our Member Services Department -- Our customer service professionals can respond to most issues when members call our Member Services department. If the issue cannot be resolved during the call, the customer service professional researches the inquiry and then responds to the member. Our goal is to respond to all inquiries within 15 business days.

    Filing a Grievance -- Members who are not satisfied with the customer service professional's response may file an oral or written grievance. The Regional Complaint and Appeals unit will send written notice to the member acknowledging receipt of the formal grievance within five working days, unless otherwise mandated by state law. The unit will investigate the grievance and respond to the member in writing. If the member is not satisfied with the outcome, the member may appeal the decision and may request additional review.

    Requesting a Hearing – The appeal process regarding hearings varies by state. In those states where a hearing is available, instructions for requesting a hearing are included with the original grievance decision. The member must request a hearing within 30 working days after receiving a response to his/her grievance. Hearings are held as needed (but no more than 45 days after the request). The appeal hearing is usually held at a location where the member may attend. Members may consult their Evidence of Coverage for additional details or contact Member Services at the telephone number on the ID card.

    Attending the Appeal Hearing -- The member has the right to appear in person, participate by teleconference or choose not to appear at the hearing. In addition, the member has the right to question the representative of Aetna designated to appear at the hearing and any other witnesses, and present his/her case. The appeal committee's decision will be rendered in writing to the member within five working days of the conclusion of the appeal hearing. The member will be notified in writing of the outcome of the hearing.

    Initiating an External Review -- Once all internal reviews have been exhausted, a member may request an external review if the denial meets the criteria (denied based on medical necessity, experimental or investigational procedures, and the cost of the service or treatment at issue for which the member would be financially responsible exceeds $500). If the member's state has a mandated external review process, we follow the state's requirements.

    The above procedures and process must be exhausted prior to the filing of an appeal with the state regulatory authority or the institution of any litigation in court or arbitration regarding the subject matter of the inquiry, grievance or grievance appeal (unless otherwise provided by law).

    Elect Choice EPO, Open Access Elect Choice EPO, Managed Choice POS, Open Access Managed Choice POS, Open Choice PPO, Traditional Choice
    There are both formal and informal ways for members to communicate concerns. Many potential issues are resolved by calling a customer service professional at our toll-free Member Services number. Our Executive Response unit tracks formal executive complaints and complaints filed through state insurance departments. We also have a National Appeals Policy (capped as below) in place regarding claims determinations. Still, our experience has shown that formal appeals are less frequent when direct discussions take place between the Aetna physician reviewer and the member’s treating physician.

    In addition, members can submit a complaint through our Internet site at www.aetna.com. The complaint is then entered into our tracking system, and the process continues on the same basis as if it were received by telephone.

    Appeals Process
    Our National Appeals Policy is modified if local state law requires specific procedures or regulation or if contractual provisions provide differently.
    To start the process, the member or provider submits a written or verbal appeal of our coverage decisions. Within five business days of receipt of written request of an appeal, an acknowledgment letter is sent. This letter states that the member, provider and facility will receive a response no later than 30 days from receipt of the appeal.

    For all types of appeals, if the member, provider or facility submitted information, a comprehensive review letter explaining the reason for the appeal determination is sent no later than 30 days from receipt of the information. If no information was submitted, a comprehensive review letter explaining the reason for the denial is sent no later than 30 days from receipt of the appeal.

    If additional time is needed to reach a decision, a letter is sent to the member or provider explaining the reason for the delay and setting a new decision date. Expedited appeals determinations are made within two business days.

    Service representatives review non-clinical denial appeals with assistance from their supervisor or the local medical director, if needed. Clinical denial appeals go through two levels of physician review. The specific steps in our decision-making process may include a review of the following:

    • Applicable policy or contract language
    • Claims and utilization management guidelines and policies
    • The relevant medical records


    The following people may be involved in the appeals process, if needed:

    • Attending provider, unless the provider refuses to participate
    • Benefits, risk policy and claims personnel
    • Customer service professionals
    • Legal advisors
    • Our medical policy personnel
    • Our technology assessment and policy staff about investigational or other status
    • Providers in the same or similar specialty as the attending provider
    • Others, as appropriate to the issues raised by the appeal


    If an appeal is denied, the written notice includes all specific reasons for the denial, including the clinical rationale, reference to applicable plan provisions, medical information reviews and any other applicable appeal procedures that may be available.

    The External Review Program is communicated at the last level of internal appeal. If the coverage denial meets the criteria (denied based on medical necessity, experimental or investigational procedures, and the cost of the service or treatment at issue for which the member would be financially responsible exceeds $500), we inform the member of the external review process and send a form to initiate the process. If the member's state has a mandated external review process, we follow the state's process.

  22. How do I appeal a claim payment or denial?

    HMO, Open Access HMO, QPOS, USAccess
    Our grievance and appeals process is outlined below.

    Calling Our Member Services Department -- Our customer service professionals can respond to most issues when members call our Member Services department. If the issue cannot be resolved during the call, the customer service professional researches the inquiry and then responds to the member. Our goal is to respond to all inquiries within 15 business days.

    Filing a Grievance -- Members who are not satisfied with the customer service professional's response may file an oral or written grievance. The Regional Complaint and Appeals unit will send written notice to the member acknowledging receipt of the formal grievance within five working days, unless otherwise mandated by state law. The unit will investigate the grievance and respond to the member in writing. If the member is not satisfied with the outcome, the member may appeal the decision and may request additional review.

    Requesting a Hearing – The appeal process regarding hearings varies by state. In those states where a hearing is available, instructions for requesting a hearing are included with the original grievance decision. The member must request a hearing within 30 working days after receiving a response to his/her grievance. Hearings are held as needed (but no more than 45 days after the request). The appeal hearing is usually held at a location where the member may attend. Members may consult their Evidence of Coverage for additional details or contact Member Services at the telephone number on the ID card.

    Attending the Appeal Hearing -- The member has the right to appear in person, participate by teleconference or choose not to appear at the hearing. In addition, the member has the right to question the representative of Aetna designated to appear at the hearing and any other witnesses, and present his/her case. The appeal committee's decision will be rendered in writing to the member within five working days of the conclusion of the appeal hearing.

    Initiating an External Review -- Once all internal reviews have been exhausted, a member may request an external review if the coverage denial meets the criteria (denied based on medical necessity, experimental or investigational procedures, and the cost of the service or treatment at issue for which the member would be financially responsible exceeds $500). If the member's state has a mandated external review process, we follow the state's requirements.

    The above procedures and process must be exhausted prior to the filing of an appeal with the state regulatory authority or the institution of any litigation in court or arbitration regarding the subject matter of the inquiry, grievance or grievance appeal (unless otherwise provided by law).

    Elect Choice EPO, Open Access Elect Choice EPO, Managed Choice POS, Open Access Managed Choice POS, Open Choice PPO, Traditional Choice
    There are both formal and informal ways for members to communicate their quality-of-care and claims payment concerns. Many potential issues are resolved by calling a customer service professional at our toll-free Member Services number. Our Executive Response unit tracks formal executive complaints and complaints filed through state insurance departments. We also have in place a National Appeals Policy (capped as below) regarding claims determinations. Still, our experience has shown that formal appeals are less frequent when direct discussions take place between the Aetna physician reviewer and the member’s treating physician.

    In addition, members can submit a complaint through our Internet site at www.aetna.com. The complaint is then entered into our tracking system, and the process continues on the same basis as if it were received by telephone

    Appeals Process
    Our National Appeals Policy is modified if local state law requires specific procedures or regulation or if contractual provisions provide differently.
    To start the process, the member or provider submits a written or verbal appeal of our coverage decisions. Within five business days of receipt of written request of an appeal, an acknowledgment letter is sent. This letter states that the member, provider and facility will receive a response no later than 30 days from receipt of the appeal.

    For all types of appeals, if the member, provider or facility submitted information, a comprehensive review letter explaining the reason for the appeal determination is sent no later than 30 days from receipt of the information. If no information was submitted, a comprehensive review letter explaining the reason for the denial is sent no later than 30 days from receipt of the appeal.

    If additional time is needed to reach a decision, a letter is sent to the member or provider explaining the reason for the delay and setting a new decision date. Expedited appeals determinations are made within two business days.

    Service representatives review non-clinical denial appeals with assistance, if needed, from their supervisor or the local medical director. Clinical denial appeals go through two levels of physician review. The specific steps in our decision-making process may include a review of the following:

    • Applicable policy or contract language
    • Claims and utilization management guidelines and policies
    • The relevant medical records


    The following people may be involved in the appeals process, if needed:

    • Attending provider, unless the provider refuses to participate
    • Benefits, risk policy and claims personnel
    • Customer service professionals
    • Legal advisors
    • Our medical policy personnel
    • Our technology assessment and policy staff about investigational or other status
    • Providers in the same or similar specialty as the attending provider
    • Others, as appropriate to the issues raised by the appeal


    If an appeal is denied, the written notice includes all specific reasons for the denial, including the clinical rationale, reference to applicable plan provisions, medical information reviews and any other applicable appeal procedures that may be available.

    The External Review Program is communicated at the last level of internal appeal. If the coverage denial meets the criteria (denied based on medical necessity, experimental or investigational procedures, and the cost of the service or treatment at issue for which the member would be financially responsible exceeds $500), we inform the member of the external review process and send a form to initiate the process. If the member's state has a mandated external review process, we follow the state process.

  23. What if waiting for you to decide on my appeal would harm my health?
    Members should always seek care promptly in an emergency. We do not require precertification for emergency services, and physicians and hospitals should not withhold care in these circumstances. We do provide expedited appeals for urgent, non-emergency services. Normally these expedited appeals are reviewed within four to eight hours of receipt, but in any event no later than one business day after the receipt of the information required to conduct the review.

  24. My Explanation of Benefits says I received services that I did not have. What should I do?
    Members noting a discrepancy should call the toll-free member services number on the ID card. We will review the error and verify that the billed services were actually rendered. Providers showing a pattern of such errors are flagged in the claim system.

  25. Where can I find information about preventive care?
    Helping you maintain good health through preventive care is one of the goals of Aetna. Periodic evaluations, examinations, x-rays and lab work all contribute to keeping you in good health and will be provided under many of our health plans when your physician recommends them. These services help your physician detect potential problems at an early stage, preventing complications later. Your health can best be maintained if you follow a sensible diet, exercise regularly and seek early medical treatment when a change in bodily function occurs.

    To help you either establish or maintain good health habits, Aetna offers a variety of programs and services through its array of health plans. For instance, there are programs designed to help you stop smoking and lose weight.

    Aetna's Beginning RightSM maternity program is targeted at helping women before, during and after pregnancy. This program include a special component to help women who have been identified as being at risk for complications during pregnancy.

    We offer other programs designed to help people with chronic illnesses, such as asthma or diabetes, manage their treatment better and improve their quality of life.



  26. Does Aetna cover vision care?
    You can visit a participating optometrist or ophthalmologist for a routine eye exam without a referral subject to the benefit schedule below. There is a copayment for the exam. If you wear eyeglasses or contact lenses, the benefit schedule is 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 eyeglasses or contact lenses, the benefit schedule is as follows:

    Members to age 45 – once every 36-month period
    Members age 45 and over – once every 24-month period
    If you need a vision exam other than a routine exam, consult your participating primary care physician who can refer you to the appropriate participating eye doctor for evaluation and treatment.

    Eyeglasses and Contact Lenses
    You are eligible to 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 includes an allowance for prescription eyeglasses or contact lenses. See your Certificate of Coverage for details.



  27. Does Aetna cover flu shots?
    Aetna offers an Adult Immunization Program, an Adolescent Immunization Program, and a Pediatric Immunization Program.

  28. How can I get information regarding the Fitness Program that is offered to Aetna Members (i.e., health clubs and gyms)?
    Please contact your Member Services office at the toll-free number listed on your ID Card. If you do not have an ID card yet, please contact your employer's benefits office to obtain this toll-free number. A Customer Service Professional will send you information about the 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.

  29. 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*. Visit the Emergency Care section of the FAQ's for a description of what Aetna considers 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.

    *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.



  30. Is my child covered while in college?
    The specific eligibility rules vary based upon the plan selected by the Employer and state regulations. However, in many instances, full-time college students may be covered until age 23. Proof of full-time student status is required each year.

  31. Can I cover a dependent who lives out-of-state or my child away at school?

    HMO, Open Access HMO:
    If a dependent is residing outside the service area, but located in one of our HMO service areas, the dependent can select a PCP from the area where he/she is residing. The plan would be administered based on the plan design of the subscriber's home network. Alternatively, the dependent can select a PCP from the employee's home network and return home for routine care; however, the dependent would only receive emergency care while out-of-network.

    In certain plans, members are able to enroll in an out-of-area dependent PPO plan. Dependents not residing within a PPO service area will receive nonpreferred benefits. If they travel into a PPO service area, the higher level of benefits will apply.

    Out-of- area dependent PPO plan is not available in MD, NY, WA or in self-funded plans.

    QPOS, USAccess:
    If a dependent is residing outside the service area, but located in one of our QPOS or USAccess service areas, the dependent can select a PCP from the area where he/she is residing. The plan would be administered based on the plan design of the employee's home network. Alternatively, the dependent can select a PCP from the employee's home network and return home for routine care. The dependent may also choose to self-refer to any provider at a reduced benefit level.

    In certain plans, members are able to enroll in an out-of-area dependent PPO plan. Dependents not residing within a PPO service area will receive nonpreferred benefits. If they travel into a PPO service area, the higher level of benefits will apply.

    Out-of- area dependent PPO plan is not available in MD, NY, OK, WA or in self-funded plans.

    Elect Choice EPO, Open Access Elect Choice EPO:
    An eligible spouse/dependent child living out-of-area where another of our networks is located may choose a PCP from the network in their location. The member can request a local provider directory for the dependent's service area or they can locate participating providers through DocFind®, our online provider directory. The plan would be administered based on the plan design of the employee's home network. All medical covered expenses will be reimbursed at the preferred benefit level.

    Where there is no local network, the spouse/child can choose a PCP from the employee's home network. Should the spouse/child need to seek care, the PCP should be contacted to discuss a referral to a local provider. The plan would be administered based on the plan design of the home network.

    It is expected that covered dependents away at school will seek medical care through the student health services associated with the school, college or university. When the required care is beyond the scope of the student health services, the PCP should be contacted to review the necessity for immediate care. If the PCP determines that care cannot be delayed, the PCP selected from the home network will request referral certification for the student to obtain care locally.

    Care for a true medical emergency is always paid at the preferred benefit level.

    Managed Choice POS, Open Access Managed Choice POS:
    An eligible spouse/dependent child living out-of-area where another of our networks is located may choose a primary care physician (PCP) from the network in their location. The member can request a local provider directory for the dependent's service area or they can locate participating providers through DocFind®, our online provider directory. The plan would be administered based on the plan design of the employee's home network. All covered medical expenses will be reimbursed as preferred (in-network) or nonpreferred (out-of-network).

    Where there is no local network, the spouse/child can choose a PCP from the employee's home network. Should the spouse/child need to seek care, the PCP should be contacted to discuss a referral to a local provider. The spouse/child may also choose to self-refer to any recognized provider at a reduced benefit level.

    It is expected that covered dependents away at school will seek medical care through the student health services associated with the school, college or university. When the required care is beyond the scope of the student health services, the PCP should be contacted to review the necessity for immediate care. If the PCP determines that care cannot be delayed, the PCP selected from the home network will request referral certification for the student to obtain care locally.

    Care for a true medical emergency is always paid at the preferred benefit level. An emergency medical condition is defined for the member as 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. This definition may vary based on state regulations.

    Open Choice PPO:
    An eligible dependent living outside the employee's home network area, but living in another one of our service areas, can access care through either network. The member can request a local provider directory for the dependent's service area or they can locate participating providers through DocFind®.

    It is expected that covered dependents away at school will seek medical care through the student health services associated with the school, college, or university. When the required care is beyond the scope of the student health services, the dependent may seek care in the local community.

    All covered medical expenses will be reimbursed as preferred (in-network) or nonpreferred (out-of-network). If a local PPO network is not available, all covered medical expenses incurred will be reimbursed at the "other expenses" coinsurance rate. The employer determines the reimbursement level (typically 80 percent) for "other expenses" when the plan design is chosen.

    Care for a medical emergency is always paid at the preferred benefit level.

    Traditional Choice:
    An eligible dependent living out-of-state or attending school may visit any recognized provider.

  32. How long can my children remain covered?
    Eligible dependent children are typically covered until age 19, except for full-time students who are usually covered until age 23. Employers may choose to extend coverage for full time students beyond age 23. Please check with your employer or plan documentation for details.

  33. How long can my child be covered if he or she has disabilities?
    Coverage for an incapacitated child can continue as long as the dependent meets the handicapped child requirements specified in the plan of benefits selected by the Employer.

    HMO, Open Access HMO, QPOS, USAccess:
    In most cases, the dependent child must become incapacitated prior to the limiting age. The limiting age is determined by the employers age limit for dependents based on student and non-student eligibility. To provide coverage for an incapacitated child, we request a letter from the dependent's family physician providing the information needed to establish that the dependent child meets the necessary requirements. The 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:
    The employee completes a continuation of coverage form to request coverage for an incapacitated child and has the attending physician complete an attending physician's statement of mental retardation or physical handicap. This form is designed to provide the information needed to establish that the dependent child meets the necessary requirements. Both forms would then be submitted to the employer for review and signature before forwarding to the claim office.

    We review the forms and approve or deny the application, enter a notice in our claim system to record the decision and notify the employer. If approved, the coverage is reviewed again two years after initial approval or as necessary based on the outcome of the initial review. Depending upon the circumstances and the dependent child's potential for rehabilitation, we may exercise our right to require proof of continued incapacity once a year, or an examination of the dependent child as often as reasonable and necessary when there is a question about incapacity.

  34. How do I order additional ID cards?
    Members can order an ID card by calling the toll-free member services number on their ID card or by visiting our Aetna Navigator™ site.

  35. Do I need to carry my ID card with me at all times?
    It is suggested that members always carry their ID card with them.

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

  37. What happens to my coverage if I move out of the area?
    For HMO, Open Access HMO, QPOS, USAccess, 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.

  38. What happens to my coverage if I turn 65?
    Generally, if you are age 65 or older and actively-at-work, there will be no change to your coverage.

    When you become Medicare-eligible, you can convert to our Golden Medicare Plan if one is available within your service area, subject to any federally mandated exclusions, and the plan is offered through your employer.

  39. What happens to my coverage if I retire?
    There are several options available to an employee who retires depending on the plan and benefits offered by their employer. The options may include:

    • If eligibility includes coverage for retirees, the retiree can remain under the regular plan. Once the retiree becomes eligible for Medicare, we would coordinate benefits with Medicare.

    • If the employer offers a separate retiree plan, the retiree could elect that plan.

    • If the employer does not offer a retiree plan or does not allow retirees to maintain coverage under the active plan, the retiree could be eligible for Medicare (if they meet the age requirement).

    • If the retiree is not eligible for any of the above, they can utilize COBRA until eligible for Medicare, or purchase an individual policy until eligible for Medicare.


  40. What if I become disabled?
    In accordance with HIPAA, we cannot refuse health coverage to an eligible employee who is not actively-at-work (i.e., disabled) or a confined dependent. However, the individual must still meet the definition of an eligible employee. It is up to the employer to make that determination. If the member is considered an eligible employee, coverage is effective on the group's effective date.

    If the person who becomes disabled is already a member, as long as the employer keeps the employee on the plan and continues to pay premiums, disabled employees will qualify for standard benefits as described in the member' 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.

  41. What if my spouse and I divorce?
    The employee/employer needs to submit a termination request if the spouse is no longer going to be covered under the plan. An ex-spouse can be covered (usually on COBRA or an individual policy) if coverage is mandated by divorce decree. This varies by state.

  42. What do I do if I need care while traveling?

    All Plans:
    We cover emergency care, no matter where. An emergency medical condition is defined for the member as 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. This definition may vary based on state regulations.

    HMO, Open Access HMO:
    A member seeking urgent care for unforeseen illness or injury while out of the service area can visit any recognized facility or provider and be reimbursed all but the appropriate copay. No prior authorization or referral is needed.

    For non-emergency services, members are required to obtain services from network providers. You are covered only for emergency and urgent care once you travel outside your HMO's service area.

    Elect Choice EPO, Open Access Elect Choice EPO:
    A member seeking urgent care while out of the service area can visit any recognized facility or provider and be reimbursed all but the appropriate copay. No prior authorization or referral is needed.

    For non-emergency services, members 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, USAccess:
    A member seeking urgent care while out of the service area can visit any facility or provider and be reimbursed all but the appropriate copay. No prior authorization or referral is needed.

    For routine medical treatment, a member is responsible for contacting the PCP for a referral to a physician outside of the home network in order to receive benefits and pay a copay. Members may also access nonparticipating providers at the non-referred benefit level, subject to deductible and coinsurance.

    Managed Choice POS, Open Access Managed Choice POS:
    Our networks offer reciprocity nationally; members 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 the home network.

    Members who are traveling can call member services or access DocFind®, our online provider directory, to find a participating provider in their location. Members should call their PCP for a referral in non-emergency situations. Members also have access to non-participating providers at the non-preferred benefit level.

    Open Choice PPO:
    Our networks offer reciprocity nationally; members 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 the home network.

    Members who are traveling can call member services or access DocFind®, our online provider directory, to find a participating provider in their location. Members also may access non-participating providers at the nonpreferred benefit level.

    Traditional Choice:
    Members may access care through any recognized provider.



  43. 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, members 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, USAccess:
    For routine medical treatment, a member is responsible for contacting the PCP for a referral to a physician outside of the home network in order to receive benefits and pay a copay. Members may also access nonparticipating providers at the non-referred benefit level, subject to deductible and coinsurance.

    Managed Choice POS, Open Access Managed Choice POS:
    Our networks offer reciprocity nationally; members 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 the home network. Members who are traveling can call the member services number on their ID card or access DocFind®, to find a participating provider in their location. Members should call their PCP for a referral in non-emergency situations. Members also have access to non-participating providers at the non-preferred benefit level.

    Open Choice PPO:
    Our networks offer reciprocity nationally; members 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 the home network. Members who are traveling can call the member services on their ID card or access DocFind®, to find a participating provider in their location. Members also may access non-participating providers at the non-preferred benefit level.

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

  44. What emergency coverage do I have while I am traveling?
    We cover emergency care, no matter where. An emergency medical condition is defined for the member as 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. This definition may vary based on state regulations.

  45. How can I get information about Alternative Health Care Programs?
    The Alternative Health Care Programs from Aetna offer you access to reduced rates on alternative therapies and products, including visits to acupuncturists, chiropractors, massage therapists and nutritional counselors. Participants can also save on vitamins, herbal supplements, books and many other health-related products such as aromatherapy, foot care, and natural body care.

  46. What are pre-existing conditions and how do they impact coverage?
    A Pre-existing condition is a health condition (other than a pregnancy) or medical problem that was diagnosed or treated during a specified timeframe prior to enrollment in a new health plan. Some pre-existing conditions may be excluded from coverage during a specified timeframe after the effective date of coverage in a new health plan. Plan documents will provide specific information on pre-existing conditions.

    The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was signed into law on August 21, 1996. This law includes important new protections for millions of working Americans and their families who have pre-existing medical conditions or who might suffer discrimination in health coverage based on a factor that relates to the individual's health.

    HIPAA includes provisions that:
    • Limit exclusions for pre-existing conditions.
    • Prohibit discrimination against employees and dependents based on their health status.
    • Guarantee renewability and availability of health coverage to certain employees and individuals.


  47. When does coverage begin?
    New employees are eligible for medical coverage effective on their date of hire and are allowed 31 days to complete their enrollment information. Their coverage becomes effective after complete enrollment data has been received.

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



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