California Insurance Code 10181.7(d); Health & Safety Code 1385.07(d))
Health insurance premiums are a direct reflection of the growing cost of health care services. These types of premium increases – which have a greater impact on rates for individual and small group health plans, as opposed to plans for our larger customers - are being propelled by the increasing prices of hospital care, prescription drugs, doctor’s visits, and other health care services. Other underlying cost pressures—from the underpayments for government insurance to the rising rates of obesity—also drive up premiums
In addition to certain groups of customers being impacted by the increased costs of health care services, certain geographic areas are also experiencing more significant difficulties with the increasing cost of health care services.
These rate changes apply to Small Group HMO Plans/ Small Group Insurance Policies renewing from 07/01/2011 through September 30, 2011 and are guaranteed for 12 months. These rates also apply to new business after 07/01/2011.
Access to MCG Criteria for Members
If you received a denial letter based on MCG criteria that says a link to MCG criteria is available online, you can access the MCG criteria at the link below. To access the MCG criteria, enter the following information from your denial letter:
Member Payment Estimator for Massachusetts Members
If a service or procedure is not listed in the Member Payment Estimator in Navigator, a Massachusetts member can obtain an estimated cost by completing the appropriate Member Request for Estimate Form.
Extension of Benefits
A subscriber or dependent may be eligible for continued coverage under the Aetna benefits plan if the subscriber's plan would otherwise terminate but the plan includes a provision for continued coverage for total disability and the subscriber or dependent initiates a request for continued coverage by contacting Aetna Member Services.
The individual who is totally disabled must meet the extension eligibility requirements on the date that coverage would otherwise end.
If the request for continued coverage is approved, the continued coverage applies only to the individual who is disabled and not to other family members. In addition, the terms of coverage at the time of the approved extension remain in effect and the continued coverage would be subject to all plan provisions and limitations.
The following forms must be completed and submitted to Aetna Member Services for consideration. Contact Aetna Member Services using the phone number listed on back of the Aetna Member ID card to obtain the mailing address.
Request for Extension of Benefits due to Total Disability requires an attending physician statement from the treating practitioner(s) supporting the request.
Handicapped Child Attending Physician's Statement/Behavioral Health Attending Physician's Statement for behavioral health conditions (all ages) and medical conditions for dependents age 18 and younger.
Adult Medical Attending Physician Statement for medical conditions for subscribers and dependents over the age of 18.
Present on Admission Indicator Code
Effective 10/1/2008, Present on Admission (POA) indicator codes will be required for determining appropriate DRG (Diagnosis Related Grouping) assignment and thus pricing. The code is required for both Commercial and Medicare lines of business. A POA code is a code used to indicate if the corresponding diagnosis was present at the time of admission. A POA code is required for all primary and secondary diagnosis codes; however a POA code is not needed for the admitting diagnosis code. Refer to the below for a list of POA indicator codes.
Value in the POA - Field Meaning
New York members can obtain an estimated cost for out-of-network services by completing the appropriate Member Request for Estimate Form, or by visiting the FAIR Health, Inc.* website.
*FAIR Health Marks and the FAIR Heath Logo are trademarks or registered trademarks of FAIR Health, Inc.
Member Payment Estimator for Rhode Island Members
If a service or procedure is not listed in the Member Payment Estimator in Navigator, a Rhode Island member can obtain an estimated cost by completing the appropriate Member Request for Estimate Form.
Notice Regarding Uses and Disclosures of Protected Health Information (PHI)
Aetna uses or discloses your Protected Health Information (PHI) only for very specific reasons and only in accordance with Texas state and federal law. PHI is any information that Aetna creates or receives related to health that identifies an individual. This information can be electronic or in any other format.
This announcement serves as notice that any PHI that Aetna creates or receives may be subject to electronic disclosure in accordance with state and federal law.