HMO Transition of Care Coverage:
California HMO Transition of Care Coverage Policy: English
California Rate Filing Information
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 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)
Confidentiality for victims of domestic violence
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.
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.
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.
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.
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.
(This form requires a statement from the treating practitioner(s) supporting the request.
(For behavioral health conditions in children and adults, and medical conditions in dependents age 18 and younger.)
(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.
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.
Help with a surprise bill
New York members who received a surprise bill from a nonparticipating provider can get help. Find more information here:
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.