Aetna® Medicare provider directory information

When you need to:

Visit an in-network health care provider

Providers in this directory have agreed to give you health care services. You can go to any of these in-network providers. But some services might need a referral.

For some plans, you may have to choose one of our network providers to be your PCP, or primary care provider. (We often use the term “PCP” in the directory.)

Visit an out-of-network health care provider

In some cases, you can get covered care from an out-of-network provider. But you may pay more out of pocket.

If an out-of-network provider sends you a bill, don’t pay it. Send it to us to process. We’ll figure out your cost-sharing amount, if any. Our claims and billing address is on your Aetna member ID card.

Get prior authorization (PA) through your provider

Some in-network services, like hospital stays or outpatient surgery, need prior authorization (PA) from Aetna Medicare. This means we have to approve the service before we’ll cover it. You can check your Evidence of Coverage for a list of these services.

If you need a service that needs PA, have your network provider contact us. They’ll need to get PA from us before they can treat you. If your plan includes out-of-network benefits and you choose to get covered services from an out-of-network provider, you can ask the provider to contact us for PA.

Find 24/7 emergency care when you need it

If you need emergency care, you’re covered 24 hours a day, 7 days a week, anywhere in the world.

Here’s what to do first:

• Call the local emergency hotline (like 911) or go to the nearest emergency facility.
• Tell your primary care provider (PCP) as soon as you can after you get treatment.
• If a delay in treatment won’t harm your health, call your PCP first.
• Tell your PCP or Aetna Medicare as soon as you can if you’re admitted to a hospital.

You can get urgent care from:

• A private practice physician
• A walk-in clinic
• An urgent care center or an emergency room

For HMO plans: When you’re in your plan’s service area, you’ll need to use health care providers in your network for urgent care, unless they’re not available. When you’re outside your plan’s area, you can see any licensed provider for urgent care. With most plans, you can see any provider in our network across the U.S. at in-network costs.

For PPO plans: You can use an out-of-network provider, but you may pay more to use one. This is whether you’re in your plan’s area or out. We’ll look at the info your provider gives us. We may need more details if the urgent or emergency issue doesn’t qualify for coverage.

Follow-up care after an emergency

Your PCP should manage all follow-up care. Some examples of follow-up care are:

• Suture removal
• Cast removal
• X-rays
• Clinic and emergency room revisits

For HMO plans: We may cover follow-up care with out-of-network providers if you have both:

1. A referral from your PCP
2. Prior authorization from Aetna

For PPO plans: We’ll cover in-network and out-of-network follow-up care after emergencies, within the rules of your plan.

If you need a referral: If your plan needs a referral for any follow-up care, you’ll need to get one before we cover it. This is the case whether you get care in or out of your plan’s service area. If your HMO plan doesn’t need a referral, you should call us before you get follow-up care at out-of-network places. You can reach us toll-free at 1-800-282-5366 ${tty}. We’re here Monday to Friday, 8 AM to 8 PM.

Visitor travel benefit

Some Aetna Medicare Advantage plans offer a visitor travel benefit. With this, you may be able to see providers in our network across the U.S. And get covered services at in-network costs when you do. PCP and referral rules would still apply. You would need to choose a PCP in the travel area for your plan to cover those services. Learn more about visitor travel benefits.

If you need emergency care, you’re covered 24 hours a day, 7 days a week, anywhere in the world. Learn more in our “For emergency care” section.

In-network care

For California HMO members, Aetna contracts with independent practice associations (IPAs) or medical groups. An IPA is group of health care providers. The group may include hospitals, primary care doctors and specialists. They are each independently owned. But they work as a group to give members care.

Aetna uses IPAs to provide California HMO members with health care services. These providers can be found in our directory.

Your PCP

California HMO members will need to choose a PCP that is with an IPA. If you don’t choose a PCP and IPA, we will choose them for you, in or near your ZIP code. If you change your PCP, your IPA will change with them.

Your PCP will refer you for health care and specialist care within their IPA. If you don’t get a referral, you’ll need to pay for that care.

Out-of-network care

If you have a California HMO plan, you’ll have to pay for out-of-network care.

Emergency care

We’ll cover emergency or urgent care from licensed providers in or out of our network.

In-network care

Prime members will need to use providers in our network for us to cover your care. Each Prime plan has its own network of providers.

Your PCP

Members of some Prime plans will have to choose a PCP. And members of some Prime plans will need a referral for specialist or places for some health care services. Check your plan details to learn more.

Out-of-network care

If you have the Prime HMO plan, you’ll have to pay for most out-of-network care. If you have the Prime PPO plan, we’ll pay for part of your out-of-network care, but you may pay more out of pocket. If you get out-of-area kidney dialysis on either plan, we’ll cover it even if the provider isn’t part of the Prime network.

Emergency care

We’ll cover emergency or urgent care from licensed providers in or out of network.

In-network care

Standard HMO members will need to use providers in our network for us to cover your care.

Your PCP

Standard HMO members will need to choose a PCP. You’ll need to get most of your health care from your PCP. Your PCP can give you referrals to specialists and places for some health care services. And for some types of care, your PCP will need to get prior authorization from Aetna Medicare. Check your plan details to learn more.

Out-of-network care

Standard HMO members will have to pay for most out-of-network care. If you get out-of-area kidney dialysis, we’ll cover it even if the provider isn’t part of the Standard HMO network.

Emergency care

We’ll cover emergency or urgent care from licensed providers in or out of network. You won’t need a referral.

In-network care

Open Access HMO members will need to use providers in our network for us to cover your care.

Your PCP

Open Access HMO members don’t have to choose a PCP. And you don’t need a referral to see network providers for covered services.

Out-of-network care

Open Access HMO members will have to pay for most out-of-network care. If you get out-of-area kidney dialysis, we’ll cover it even if the provider isn’t part of the Open Access HMO network.

Emergency care

We’ll cover emergency or urgent care from licensed providers in or out of network.

In-network care

HMO-POS members will need to use providers in our network for us to cover your care.

Your PCP

HMO-POS members will need to choose a PCP. You’ll need to get most of your health care from your PCP. Your PCP can give you referrals to specialists and places for some services. And for some types of care, your PCP will need to get prior authorization from Aetna Medicare. Check your plan details to learn more.

Out-of-network care

HMO-POS members will have to pay for most out-of-network care. If you get out-of-area kidney dialysis, we’ll cover it even if the provider isn’t part of the HMO-POS network.

Emergency care

We’ll cover emergency or urgent care from licensed providers in or out of network. You won’t need a referral.

In-network or out-of-network care

PPO members don’t have to use providers in our network for us to cover your care. But providers that aren’t in our network don’t have a contract with us. That means that they don’t have to treat our members, unless it’s an emergency.

To be sure: You may want to know if your plan will cover an out-of-network service. If so, you or your provider can ask us for a “pre-service organization determination.” If you do, we’ll let you know if your plan covers the service.

You can call us at the number on your Aetna member ID card. Or check your Evidence of Coverage for more info. Like your cost share for out-of-network services.

If you receive covered services from an out-of-network provider, it’s important to confirm that they:

• Accept your PPO plan
• Can accept Medicare payment

Your PCP

In most plans, PPO members don’t have to choose a PCP. But we think it’s best if you do. Members will have to choose one if you have a C-SNP (Chronic Condition Special Needs Plan).

Emergency care

We’ll cover emergency or urgent care from licensed providers in or out of network.