Medicare Advantage HMO or PPO Plan Members Without a Medicare Prescription Drug Benefit Rights
As an Aetna Medicare Advantage HMO or PPO Plan Member without a Medicare prescription drug benefit, you have a right to:
- Get information from Aetna about our plan. This includes information about our financial condition, and how our plan compares to other health plans.
- Get information from us about our network.
- Get information from us in a way that works for you. Our plan has people and free language interpreter services available to answer questions from non-English speaking members. We can also give you information in Braille, in large print, or other alternate formats if you need it.
- Get an explanation from Aetna about any Part C medical care or service not covered by our plan.
- Receive in writing why we will not pay for or approve a Part C medical care or service, and how you can file an appeal to ask us to change this decision even if you obtain the Part C medical care or service from a provider not affiliated with our organization.
- Make a complaint if you have concerns or problems related to your coverage.
- Be treated fairly (that is, not be retaliated against) if you make a complaint.
- Get a summary of information about the appeals and grievances that members have filed against our plan in the past.
- Get more information about your rights. If you have questions or concerns about your rights and protections, you can
- Call Aetna Member Services
- Get free help and information from your State Health Insurance Assistance Program (SHIP).
- Visit www.medicare.gov to read or download the publication, Your Medicare Rights & Protections.
- Call 1-800-Medicare (1-800-633-4227) 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
- Call the Office for Civil Rights (1-800-368-1019). TTY users should call (1-800-537-7697) if you think you've been treated unfairly or your rights have not been respected.
Access to care
- Choose a network health care provider.
- Timely access to providers. Timely access means that you can get services within a reasonable amount of time.
- Go to a women's health specialist (such as a gynecologist) in our plan without a referral.
- If you have a disability and need help with access to care, please call Aetna Member Services.
The freedom to make decisions
- Get full information from your health care providers when you go for medical care.
- Participate fully in decisions about your health care. Your health care providers must explain things in a way that you can understand. Your rights include knowing about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our plan.
- Be told about any risks involved in your care.
- Be told beforehand if any planned medical care or treatment is part of a research experiment. You must and be given the choice of refusing experimental treatments.
- Refuse treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. This includes the right to stop taking your medication.
- Receive a detailed explanation from Aetna if you think a health care provider denied care that you believe you were entitled to receive or care you believe you should continue to receive. In these cases, you must request an initial decision, called an organization determination.
- Ask someone such as a family member or friend to help you with decisions about your health care.
- Give your doctors written instructions about how you want them to handle your medical care, such as Advanced Directives, Living Will, and Power of Attorney for Health Care, if you become unable to make decisions for yourself. You can contact member services to ask for the forms.
- Be treated with dignity, respect and fairness at all times. Aetna must obey laws that protect you from discrimination or unfair treatment. Aetna does not discriminate based on a person's race, mental or physical disability, religion, gender, sexual orientation, health status, ethnicity, creed, age, claims experience, medical history, genetic information, evidence of insurability, geographic location within the service area or national origin.
- The privacy of your medical records and personal health information, according to federal and state laws that protect the privacy of your medical records and personal health information. There are exceptions allowed or required by law, such as release of health information to government agencies that are checking on quality of care.
- Receive a written notice called a Notice of Privacy that tells you about privacy of your medical records and personal health information rights and explains how we protect the privacy of your health information.
- Look at medical records held at the plan, and to get a copy of your records.
- Ask Aetna to make additions or corrections to your medical records.
- Know how your health information has been given out and used for non-routine purposes.
- For a list of the providers in the plan's network, see the provider directory. For more detailed information about our providers, you can call member services or visit our website at www.aetnamedicare.com.
- Suggest changes in the plan's policies and services, including our Member Rights and Responsibilities policy.
As an Aetna Medicare Advantage HMO or PPO plan member without a Medicare prescription drug benefit, you have a responsibility to:
Exercise your rights
- Learn about your coverage and the rules you must follow to get care as a member.
- Tell your doctor or other health care providers that you are enrolled in our plan. Show you membership card whenever you get your medical care.
- Give your doctor and other health care providers the information they need to care for you.
- Follow the treatment plans and instructions that you and your doctors agree upon.
- Act in a way that supports the care given to other patients and helps the smooth running of your doctor's office, hospitals and other offices.
- Tell our plan if you have additional health insurance and use all of your insurance coverage.
- Pay your plan premiums and copayments/coinsurance for your covered services.
- Pay for services that aren't covered.
- If you have any questions, ask your doctors and other health care providers and have them explain your treatment in a way you can understand.
- Let Aetna know if you move.
Let us know if you have any questions, concerns, problems or suggestions.