Medicare Advantage HMO or PPO, Plan With a Medicare Prescription Drug Benefit Included in the Plan Design Rights and Responsibilities
As a Member in a Medicare Advantage HMO or PPO plan with a Medicare Prescription Drug Benefit included in the plan design, you have a right to:
- Get information from Aetna about our plan. This includes information about how we are doing financially, and how our plan compares to other health plans.
- Get information from us about our network.
- Have questions from non-English speaking beneficiaries answered. We make individuals and translation services available, and the information we provide about our benefits must be accessible and appropriate for people who are eligible for Medicare because of disability.
- Get an explanation from Aetna about any prescription drugs, Part C medical care or service not covered by our plan.
- Receive in writing why we will not pay for or approve a prescription drug, 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 prescription drug, or Part C medical care or service from a pharmacy or provider not in the Aetna network.
- Receive an explanation from us about any utilization-management requirements, such as step-therapy or prior authorization, which may apply to your plan.
- 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 view 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.
- Go to a women's health specialist in our plan (such as a gynecologist) without a referral.
- Timely access to providers. Timely access means that you can get services within a reasonable amount of time.
- Get your prescriptions filled within a reasonable period of time at any network pharmacy.
The Freedom to make decisions
- Get full information from your health care providers when you go for medical care. This includes 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.
- 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.
- Know about the different medication therapy management programs we offer in which you may participate.
- 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 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 has denied care 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.
- Get information from us about our network pharmacies, health care providers and their qualifications, as well as information about how we pay our doctors.
- For a list of the providers and pharmacies in the plan's network, see the provider directory. For more detailed information about our providers or pharmacies, 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 a member in a Medicare Advantage HMO or PPO plan with a Medicare Prescription Drug Benefit included in the plan design, you have a responsibility to:
Exercise your rights
- Learn about your coverage and the rules you must follow to get care as a member.
- Unless it is an emergency, when seeking care let health care providers know that you are enrolled in our plan and present your plan membership card to the provider.
- 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 or drug coverage 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.
- Ask your doctors and other providers if you have any questions and have them explain your treatment in a way you can understand.
- 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 or Part D prescription drugs.
- Let Aetna know if you move.
- Let us know if you have any questions, concerns, problems or suggestions.