2012 Aetna Benefits Products

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23.02.804.1 G (4/12)
PCP
selection
PCP
referral Phone number
Benefit Category 1
• Patients must select and use a participating primary
care provider (PCP) and receive PCP-referred care
through participating providers.
• Services outside of Aetna’s participating provider
network are not covered, except emergency/
out-of-area urgent care or out-of-area renal dialysis,
unless approved by the Health Maintenance
Organization (HMO) in advance of receiving services.
Aetna Medicare
SM
Plan (HMO) R R 1-800-624-0756
Aetna Select
SM
R R 1-888-MDAetna
Elect Choice
®
(EPO) R R 1-888-MDAetna
HMO R R 1-800-624-0756 ( for HMO
members with a “W” identification
number call 1-888-MDAetna)
Benefit Category 2
• Patients receive highest benefits level by selecting and
using a participating PCP and receiving PCP-referred
care through participating providers.
• Patients receiving covered services from a
nonparticipating provider are subject to
out-of-network deductibles, coinsurance and
potential balance billing.
Managed Choice
®
POS R E 1-888-MDAetna
Quality Point-of-Service
®

(QPOS
®
)
R E 1-800-624-0756 ( for QPOS
members with a “W” identification
number call 1-888-MDAetna)
Benefit Category 3
• Patients are encouraged to select and use
a participating PCP.
• Services received outside of Aetna’s participating
provider network are not covered, except emergency/
out-of-area urgent care or out-of-area renal dialysis
unless approved by Aetna in advance of receiving
services.
Aetna Medicare
SM
Plan (HMO)
Open Access
E NR 1-800-624-0756
Aetna Health Network Only
SM
See
ID Card
See
ID Card
1-888-MDAetna
Aetna Open Access
®
Elect
Choice
®
E NR 1-888-MDAetna
Aetna Open Access
®
HMO E NR 1-800-624-0756
Open Access Aetna Select
SM
E NR 1-888-MDAetna
Benefit Category 4
• Patients are encouraged to select and use a
participating PCP.
• Patients receiving covered services from a
nonparticipating provider are subject to
out-of-network deductibles, coinsurance and
potential balance billing.
Aetna Choice
®
POS E NR 1-800-624-0756
Aetna Choice
®
POS II E NR 1-888-MDAetna
Aetna Medicare
SM
Plan (PPO) E NR 1-800-624-0756
Aetna Health Network
Option
SM
See
ID Card
See
ID Card
1-888-MDAetna
Aetna Open Access
®

Managed Choice
®
E NR 1-888-MDAetna
Benefit Category 5
• Patients receiving covered services from a
nonparticipating provider are subject to out-of-
network deductibles, coinsurance and potential
balance billing.
Aetna Limited Benefits
Insurance Plan
®
(PPO)*
NR NR 1-888-772-9682
Open Choice
®
PPO NR NR 1-888-MDAetna
Benefit Category 6
• Patients have access to all licensed providers
for covered benefits.
• Patients are responsible for all applicable deductibles,
coinsurance and potential balance billing.
Aetna Voluntary Group
Medical Plan
®
(Indemnity
Plan)*
NR NR 1-888-772-9682
Traditional Choice
®
NR NR 1-888-MDAetna
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life
Insurance Company and its affiliates (Aetna).
Required (R); Not Required (NR); Encouraged (E)
*Formerly Aetna Affordable Health Choice
Aetna benefits and products
Precertification**
• The admitting or treating physician is responsible for
precertification. Patients who have a plan with an out-of-network
benefit, who choose a nonparticipating provider, are required
to precertify those services themselves. Precertification is not
required, but is recommended, for the Aetna Medicare Plan (PPO).
• Access the list of services requiring precertification via
www.aetna.com. Go to “Health Care Professionals,” “Policies
and Guidelines,” then “Precertification.” Information is also
available by calling the precertification phone number on the
patient’s member ID card.
Laboratory
†
• Direct patients to participating laboratories (some markets may
require the use of a capitated laboratory).
• For stat lab work, direct patients to a participating facility.
Radiology
†

• Direct patients to a participating radiology provider (some markets
may require the use of a capitated radiology facility).
Aetna HealthFund
®
Health Reimbursement Arrangement (HRA)
The Aetna HealthFund family of products blends an employer-
established health fund with a deductible-based benefits plan.
This means it is comprised of a fund, a deductible and a base
medical benefits plan. The underlying product designation can be
found on member ID cards, or through electronic member eligibility
verification. For more information on PCP selection and referral
requirements, refer to the base health products listed on the
opposite page.
Key information about Aetna HealthFund HRA:
Patients receive highest benefits level by accessing participating
providers.
• Patients receive an allocated health fund from the employer
to assist with payments, deductibles and coinsurance.
• If the health fund is depleted, the patient is responsible for
any applicable deductibles and coinsurance.
• Health care providers should bill Aetna directly for all services.
• Member responsibility is listed on the Explanation of
Benefits (EOB).
Aetna HealthFund
®
Health Savings Account (HSA)
Our integrated HSA product is comprised of three elements: an
account, a deductible and a base medical benefits plan. This plan
differs from an HRA because members can determine when to
spend their account dollars. They may choose to use them now to
cover medical expenses, or save them for future use. The underlying
product designation can be found on the member ID cards, or
through electronic member eligibility verification. For more
information on PCP selection and referral requirements, refer to
the base health products listed on the opposite page.
Key information about Aetna HealthFund HSA:
• Patients receive highest benefits level by accessing participating
providers.
• Patients in a qualified high-deductible health plan (as defined by
the government) may enroll in an HSA on their own or through
their employer. Anyone can contribute to the HSA. Patients may
choose to use the funds in their HSA to assist with payments,
deductibles and coinsurance, or they may choose to pay for these
services out-of-pocket and save their HSA funds for future retiree
medical expenses.
• Patients are responsible for any applicable deductibles and
coinsurance and may use their HSA to help pay for these expenses.
• Health care providers should bill Aetna directly for all services.
• Member responsibility is listed on the EOB.
General information
Direct access is a feature that allows patients access to certain
services without a referral, even though the plans require referrals
for most other services. These include ob/gyn-related services,
routine vision exams by participating providers, or other direct-access
programs mandated under various state laws and regulations. This is
not to be confused with open access.
Open access is a feature of some Aetna plans that allows patients
access to all in-network services without a referral. Depending on
the plan, patients may receive a higher benefits level if they choose
providers in the network. For behavioral health benefits, please
reference the patient’s member ID card or contact our Provider
Service Center.
PCP selection and copayments — Some states require patients
to select a PCP. Other states mandate patients to pay the PCP
copayment even if the provider is not the patient’s selected PCP.
Please refer to the copayment information located in patient
eligibility and benefits via Aetna’s electronic solutions. The PCP
copayment applies to the Aetna Medicare Plan (HMO) Open Access,
as long as the physician is a PCP. Please be sure to indicate patient
paid amount on claims and encounters submitted to Aetna.
Fee schedules, member eligibility, or benefits and claims
information is available online — Log in to our secure provider
website at www.aetna.com, select “Health Care Professionals,”
then “Medical Professionals Log In.” Our secure provider website
also allows you to update your registration, billing and user profile
information; obtain information on fee schedules, benefits,
referrals and claims; as well as perform electronic transactions
24 hours a day, 7 days a week.
DocFind
®
— For physician, lab and radiology information,
visit our online provider referral directory at www.aetna.com.
Passport To Healthcare
®
is an Aetna International product.
Members who are enrolled have access to the Aetna Open Choice
®

PPO network. To learn more, visit www.AetnaEducation.com and
select “Products, Programs and Plans,” then select “Passport to
Health” under Reference Tools.
3
** The term Precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device
meets the company’s clinical criteria for coverage. It does not mean precertification as defined by Texas law, as a reliable representation of payment.
†
Some markets may require a valid physician order.
Visit our secure provider website at www.aetna.com.
Log in and select “Health Care Professionals,” then
“Medical Professionals Log In.”
The information contained in this document is only a summary of key components of Aetna’s product. For more detailed information, you must consult the
member’s plan documents (schedule of Benefits, Certificate of Coverage, Evidence of Coverage, Group Agreement, Group Insurance Certificate, Booklet,
Booklet-certificate, Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitations relating to a member’s plan.
Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to
www.aetna.com.
www.aetna.com
©2012 Aetna Inc.
23.02.804.1 G (4/12)