State Specific Information
Arkansas
Arkansas Utilization Review Statistical Report (07/01/2019-09/30/2019)
Arkansas Utilization Review Statistical Report (04/01/2019-06/30/2019)
Arkansas Utilization Review Statistical Report (01/01/2019-03/31/2019)
Arkansas Utilization Review Statistical Report (10/01/2018-12/31/2018)
Arkansas Utilization Review Statistical Report (07/01/2018-09/30/2018)
Arkansas Utilization Review Statistical Report (04/01/2018-06/30/2018)
Arkansas Utilization Review Statistical Report (01/01/2018-03/31/2018)
Arkansas Utilization Review Statistical Report (10/01/2017-12/31/2017)
Arkansas Utilization Review Statistical Report (07/01/2017-09/30/2017)
Arkansas Utilization Review Statistical Report (04/01/2017-06/30/2017)
Arkansas Utilization Review Statistical Report (01/01/2017-03/31/2017)
Arkansas Utilization Review Statistical Report (07/01/2016-12/31/2016)
Arkansas Utilization Review Statistical Report (01/01/2016-06/30/2016)
Arkansas Utilization Review Statistical Report (07/01/2015-12/31/2015)
Access to ASAM Criteria for Members
Read the Introduction to ASAM criteria for members
If you received a denial letter based on American Society of Addiction Medicine (ASAM) criteria that says a link to the ASAM criteria we used for the review is available online, you can access the ASAM criteria through the form below. Follow these steps:
- Enter the ASAM Guideline Code from your denial letter in the box below and submit;
- Read and accept the terms and conditions;
- View the criteria on the results page.
Access the ASAM criteria
Access to MCG Criteria for Members
If you received a denial letter based on Milliman Care Guidelines (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:
- Date of letter
- Member’s last name
- MCG Guideline Code (stated in the letter)
- Password (stated in the letter)
Colorado
Aetna Dental® Network Access Plan
Aetna® EPO Network Access Plan
Aetna® HMO Colorado Network Access Plan
Aetna Open Access® Managed Care Network Access Plan
Aetna® PPO Colorado Network Access Plan
Aetna Vision℠ Preferred Network Access Plan
Aetna Whole Health℠ Network Access Plan
Criteria we use to make coverage decisions
Connecticut
Access to ASAM Criteria for Members
Read the Introduction to ASAM criteria for members
If you received a denial letter based on American Society of Addiction Medicine (ASAM) criteria that says a link to the ASAM criteria we used for the review is available online, you can access the ASAM criteria through the form below. Follow these steps:
- Enter the ASAM Guideline Code from your denial letter in the box below and submit;
- Read and accept the terms and conditions;
- View the criteria on the results page.
Access the ASAM criteria
Access to MCG Criteria for Members
If you received a denial letter based on Milliman Care Guidelines (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:
- Date of letter
- Member’s last name
- MCG Guideline Code (stated in the letter)
- Password (stated in the letter)
Cost Estimator for Connecticut Members
If a service or procedure is not listed in the cost estimator in the Aetna member website, a Connecticut member can obtain an estimated cost by completing the appropriate Member Request for Estimate Form.
How We Build Our Networks
Our online provider directory gives details on our provider networks, including the factors and standards we use to build them.
Help with a surprise bill
Connecticut members who received a surprise bill from a nonparticipating provider can get help. Find more information here:
Important Information: Network provider not reasonably available
If you are enrolled in a plan that uses a comprehensive provider network, you can get covered health services from an out-of-network provider at your in network cost share if an appropriate network provider is not reasonably available. You must request access to the out-of-network provider in advance and we must agree. Contact Member Services at the toll-free number on your ID card for help starting the process.
Illinois
Enhanced Policy Liberalizations for Christian County Consumers
Note to all Illinois consumers affected by the recent significant storms in Christian County: Please read the following policy liberalizations and safeguards Aetna has put in place to help protect your health insurance coverage and give you peace of mind during your recovery process.
Maine
Cost Estimator for Maine Members
If a service or procedure is not listed in the cost estimator in the Aetna member website, a Maine member can obtain an estimated cost by completing the appropriate Member Request for Estimate Form.
Massachusetts
Massachusetts - Behavioral Health Child and Adolescent Services
For Massachusetts members seeking information on Behavioral Health care services for children and adolescents (BHCA)
Read more about these services
Massachusetts - Behavioral Health and Substance Use Disorder Precertification
Massachusetts Precertification Information for Fully-Insured Plans
Massachusetts residents must have health care coverage
Are you a Massachusetts resident? Are you age 18 or older? Can you afford health insurance? If you answered yes to all of these, you must have health coverage for the entire year according to Massachusetts Health Care Reform.
Read more about mandatory coverage in Massachusetts
Cost Estimator for Massachusetts members
If a service or procedure is not listed in the cost estimator in the Aetna member website, a Massachusetts member can obtain an estimated cost by completing the appropriate Member Request for Estimate Form.
Aetna Student Health Member
Savings Plus network
Helpful information on the Savings Plus Plan. Savings Plus doctors and hospitals are noted in our online directory.
Read more about Savings Plus
How can I change the way Aetna communicates with me?
You have the right to ask us to communicate with you in a certain way or at a certain location.
If you are on someone else’s insurance and would like us to send your Explanation of Benefits statements and other claim information to an address that’s different from the primary subscriber’s, please call Member Services at the number on your ID card.
To stop paper mailings of Explanation of Benefits and claim information, log in to your secure account and use the “Profile” link in the upper right corner to change your paper-saving preferences. Your Explanation of Benefits and claim information will still be available in your secure account.
Massachusetts Voluntary and Involuntary Disenrollment Rates
The voluntary and involuntary disenrollment rates for insureds are 0 percent. If you need a printed copy of this notice, call the number on your ID card.
For the purposes of 211 CMR 52.14(1)(c), the term “voluntary disenrollment” means that an insured has terminated coverage with the carrier for nonpayment of premium.
For the purposes of 211 CMR 52.14(1)(c), the term “involuntary disenrollment” means that a carrier has terminated the coverage of the insured due to any of the reasons contained in 211 CMR 52.13(3)(j) 2 and 3:
- Misrepresentation or fraud on the part of the insured
- Commission of acts of physical or verbal abuse by the insured which pose a threat to providers or other insureds of the carrier and which are unrelated to the physical or mental condition of the insured, provided that the commissioner prescribes or approves the procedures for the implementation of the provisions of 211 CMR 52.13(3)(i)3.
If you have any questions concerning the data disclosed above, please contact the Massachusetts Office of Patient Protection by:
- Calling them toll free at 1-800-436-7757
- Faxing your question to 617-624-5046
- Visiting mass.gov/orgs/office-of-patient-protection
New Jersey
Price Estimates:
Price estimates can be made in the Aetna member website.
If a service or procedure is not found on the Aetna member website, New Jersey 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. The estimates provided on this site will not take into account whether or not the member’s coinsurance and other plan cost-share limits when the estimate is provided.
Estimate costs of out-of-network services
Aetna Student Health Member
*FAIR Health Marks and the FAIR Heath Logo are trademarks or registered trademarks of FAIR Health, Inc.
If you would prefer a printed copy of this information, or a printed list of providers, contact Member Services at the toll-free number on your ID card.
Learn more about managing your health care costs
Important information about your out-of-network benefits
Refer to this document for Important Information on Out of Network Claims.
It covers some details on voluntary and involuntary uses of out of network providers. The information on voluntary out-of-network benefits only applies if your plan has voluntary out-of-network benefits.
How we compensate your health care providers
Health care providers are independent practicing professionals that are neither employed nor exclusively contracted with Aetna. Individual physicians and other providers are in the network by either contracting with us directly or by affiliating with a group or organization that contracts with us.
We compensate these health care providers:
- Per individual service or case (fee for service at contracted rates).
- Per hospital day (per diem contracted rates).
- Through capitation (a prepaid amount per member, per month).
- Through Integrated Delivery Systems (IDS), Independent Practice Associations (IPA), Physician Hospital Organizations (PHO), Physician Medical Groups (PMG), behavioral health organizations and similar provider organizations or groups. Aetna pays these organizations, which in turn may reimburse the physician, provider organization or facility directly or indirectly for covered services. In such arrangements, the group or organization has a financial incentive to control the cost of care.
Behavioral health network providers participate through a behavioral health organization. We pay these organizations on a capitation basis. The organization reimburses the physician, provider organization or facility on a fee for service or per diem basis for covered services.
One of the purposes of managed care is to manage the cost of health care. Incentives in compensation arrangements with physicians and health care providers are one method by which Aetna attempts to achieve this goal.
Claim Reimbursement Examples
The Claim Reimbursement Examples PDF has examples of average submitted charges and allowances for commonly billed voluntary out-of-network services. Actual charges and costs may vary. Follow the steps on this page to obtain a price estimate for any planned out-of-network covered services.
Out-of-network exceptions
You can ask for an exception to have an out-of-network service treated as a network benefit when:
- a network provider with the needed training or expertise is not available for your condition; or
- a participating provider is not accessible.
You or your provider must get pre-approval (pre-cert) from Aetna for the services to be covered. You or your provider can call the precert number on your identification card to start the process.
Doctors, chiropractors and podiatrists must inform you of certain financial interests
The laws of the State of New Jersey, at N.J.S.A 45:9-22.4 et seq., mandate that a physician, chiropractor or podiatrist who is permitted to make referrals to other health care providers in which she/he has a significant financial interest inform his or her patients of any significant financial interest he or she may have in a health care provider or facility when making a referral to that health care provider or facility. If you want more information about this, contact your physician, chiropractor or podiatrist. If you believe that you are not receiving the information to which you are entitled, contact the Division of Consumer Affairs in the New Jersey Department of Law and Public Safety at 1-973-504-6200 OR 1-800-242-5846.
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. The mailing address appears on the forms.
Request for extension of benefits due to total disability
(This form requires a statement from the treating practitioner(s) supporting the request.
Handicapped child/behavioral health attending physician's statement
(For behavioral health conditions in children and adults, and medical conditions in dependents age 18 and younger.)
Adult medical attending physician's statement
(For medical conditions in adults)
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
- Y - Diagnosis was present at the time of inpatient admission.
- N - Diagnosis was not present at the time of the inpatient admission.
- U - Documentation insufficient to determine if condition was present at the time of inpatient admission.
- W - Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of the inpatient admission.
- 1 or Spaces Unreported/not used - Exempt from POA reporting.
Health insurance carriers must inform subscribers about organ and tissue donation and registration
Health insurance carriers are now required to provide subscribers written informational materials about organ and tissue donation and registration at each contract renewal. These materials must:
(A) Be developed or approved by a federally designated organ procurement organization; and
(B) Inform subscribers on how to make an anatomical gift, including information on the registration of a gift in the Donate Life New Jersey registry.
New York
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.
Estimate costs of out-of-network services
*FAIR Health Marks and the FAIR Heath Logo are trademarks or registered trademarks of FAIR Health, Inc.
Help with a surprise bill
New York members who received a surprise bill from a nonparticipating provider can get help. Find more information here:
Surprise Billing Member Notification
Important Information on Proposed Rate Changes
NY Individual Conversion 2020 Narrative Rate Summary
NY Small Group ALIC 1Q20 thru 4Q20 Narrative Rate Summary
NY Individual Conversion 2019 Narrative Rate Summary
NY Small Group ALIC 1Q19 thru 4Q19 Narrative Rate Summary
Other Important Member Rights
NY Confidentiality Protocols for Victims of Domestic Violence and Endangered Individuals
Rhode Island
Cost Estimator for Rhode Island Members
If a service or procedure is not listed in the cost estimator in the Aetna member website, a Rhode Island member can obtain an estimated cost by completing the appropriate Member Request for Estimate Form.
Rhode Island Dental and Vision Disclosure –Appeals/Complaints/Grievances
This notice explains member rights for review of benefit determination appeals and complaints/grievances under Rhode Island state law.
Rhode Island Dental and Vision Disclosure –Appeals/Complaints/Grievances
Texas
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.
Cost Estimator for Texas Members
If a service or procedure is not listed in the cost estimator in the Aetna member website, a Texas member can obtain an estimated cost by completing the appropriate Member Request for Estimate Form.
Vermont
Cost Estimator for Vermont Members
If a service or procedure is not listed in the cost estimator in the Aetna member website, a Vermont member can obtain an estimated cost by completing the appropriate Member Request for Estimate Form.
Washington
Washington State Mental Health and Substance Abuse Disorder Network Disclosures
For state of Washington members accessing behavioral health and substance use disorder services.
