Everything you needto help you be yourhealthiest.
Make Aetna the choice for your health!New Jersey State Health Benefits Program and School Employees’ Health Benefits Program
Effective January 201019.02.300.1-NJ I (7/09)
We want you to know —
Welcome to Aetna!
There’s nothing more important
than you and your family’s health.
And now’s a great time to review
your options to make sure you pick
the plan — and the company —
that makes the healthy difference.
We’ve put together some material
to help you better understand our
program and how it can help you
and your family.
If you have questions, we’re
here for you. Just call us at
1-877-STATENJ, or visit us 24/7
at www.aetna.com/statenj.
Benefits snapshot
When you choose Aetna,* you’re choosing a lot more than simple benefits coverage.You’re also getting access to leading technology and programs that help you takecharge of your health — conveniently, and at a cost you can afford.
Here are some of the highlights of your Aetna plan:
■ Over 41,000 HMO network providers and 100 HMO network hospitals in New Jersey alone!Plus, over 784,000 HMO providers and 3,400 HMO network hospitals nationwide. So we’rewith you wherever you go.
■ Primary care physician (PCP) or specialist visits for just a copay
■ Emergency care — anytime and anywhere you need it
■ Urgent care – many participating urgent care centers in NJ
■ Coordination with top physicians and facilities to provide transplant care when it’s notavailable locally (National Medical Excellence Program®)
■ Special coverage and services for women, like direct access to Ob/Gyns — without a referral.And our Beginning Right® Maternity Program helps support growing families.
■ Mailed reminders to get regular checkups for breast, colorectal and cervical cancer, based on your age.
■ Toll-free chats with a registered nurse to get your health questions answered anytime, day ornight, through the Aetna Informed Health® Line at 1-800-556-1555.
■ 34+ programs to help you manage your asthma, diabetes, heart disease, low back pain, andother health conditions.
■ Data tools that provide medical alerts or suggestions to your doctor or pharmacist based onyour health history with us (MedQuery®).
■ An online wellness program that can help you stop smoking, eat better, relieve stress andmuch more (Simple Steps To A Healthier Life®).
■ Technology to help you manage your health, and your benefits. You can request an ID card or find a doctor, and even browse plenty of health topics that matter to you most atwww.aetna.com/statenj.
■ A dedicated claim and Member Services team.
*Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiarycompanies, which may include Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna).
We want you to know — we’re here for you
Got questions? Get answers!Call 1-877-STATENJ or visit www.aetna.com/statenj.We look forward to helping you and your familymaintain your best health. Don’t forget to sign up for Aetna at open enrollment!
The top five reasons to choose Aetna
There are lots of good reasons to choose us for you and yourfamily. But here are the ones we think you’ll like best:
1. The doctor you want — Our extensive networks, bothnationwide and in New Jersey, likely has the doctor mostimportant to you — YOURS.
2. Worry-free coordination of care — Don’t know whichspecialist to visit? You’ve got your very own PCP to help you!
3. Plenty of perks — Discounts galore on gym memberships,Jenny Craig®, Pearle Vision® and other eyewear locations,hearing aids, spa gift certificates, and more!
4. Make HistorySM — The online Personal Health Record (PHR)puts all your hard-to-find health information in one easy-to-find spot. Share it anytime with your doctor.
5. Benefits information in seconds — Accessing your benefits is just a click away at www.aetna.com/statenj. Click on Member Resources and then on AetnaNavigator®. You can check claim status, order ID cards, find a specialist, and much more.
Table of Contents
Health Benefit Plan Benefit Copay Sheet ....................2
HMO Health BenefitsProgram ........................................3
How Your Plan Works..................4
Aetna Programs and Online Resources ......................6
Disease Management ..............7
Maternity Management ..........8
Behavioral Health......................8
Personal Health Record ............9
Special Savings Programs ......10
Fitness Program ......................11
Vision Program........................12
Natural Products......................13
Hearing Program ....................14
Weight Management Program....................................15
Important Consumer Disclosure Information ..............17
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Health Benefit Plan — Benefit Copay SheetType of Service or Supply Benefit Level*
Out-of-Pocket Maximums No lifetime maximum
Inpatient Hospital ServicesRoom and Board Covered in full — no copayX-Ray and Lab Tests Covered in full — no copaySpecial Care Units Covered in full — no copayMaternity Care Covered in full — no copayWell-Baby Care Covered in full — no copaySkilled Nursing Facilities 120 days per year (Jan. through Dec.) covered in full — no copayBirthing Centers Covered in full — no copayHospice Care Covered in full — no copay
Surgery and AnesthesiaInpatient Surgery Covered in full — no copayOutpatient Surgery Covered in full — no copay
Outpatient TreatmentsOffice Visit Copays: Primary Care Physician Copay applies per visit
Specialists Copay applies per visit with referralOb/Gyn Copay applies per visit — no referral needed for any routine gynecological service
Doctor’s Home Visits Copay applies per visitX-Ray and Lab Tests Covered in fullCardiac Rehabilitation and Dialysis Copay applies per visitChemotherapy and Radiation No copayPhysical, Speech, and Occupational Therapy Covered in full — 60 visits per condition, per calendar year; copay applies per visitLicensed Chiropractor Copay applies per visit — 20 visits per year (Jan. through Dec.)Routine Examinations Covered in full — copay applies per visitRoutine Well-Baby Care Covered in full — copay applies per visitImmunizations Covered in full — copay applies per visitEye Examinations (no hardware) Covered in full — copay applies per visitHearing Examinations Covered in full — copay applies per visitHome Health Care Covered in full — no copayPodiatry (nonroutine) Covered in full — copay applies per visit
Mental and Nervous ConditionsInpatient Treatment 35 days per year (Jan. through Dec.) covered in full — no copayOutpatient Treatment 30 visits per year (Jan. through Dec.) covered in full — copay applies per visitAlternate Care Facilities Covered in full —-for acute residential treatment only
Treatment of Alcohol and Drug AbuseInpatient Treatment 28 days per occurrence covered in full — no copayOutpatient Treatment 60 visits per year (Jan. through Dec.) covered in full — no copayDetoxification Covered in full — no copay
Other ServicesInfertility Services: Diagnosis Covered in full — copay applies per visitTreatment Covered with limitations — copay applies per visitMedical Equipment Covered under Home CareDurable Medical Equipment Covered when medically necessary — subject to $100 calendar year deductible
per memberInformed Health® Line 24-hour/7-day-a-week access to registered nurses at 1-800-556-1555Ambulance Services Covered when medically necessary — no copayProsthetic Devices Covered when medically necessary — deductible appliesEmergency Care Covered in full — copay waived if admittedDental Services: TMJ Not covered
Oral Surgery Not covered — except bony impactions
Wigs in connection with treatment of disease by radiation or chemicals $500/year
*See materials distributed by the division of Pensions and Benefits for copay amounts.
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Health benefits made simpleHMO Plan
Easy-to-usebenefits
One-on-one care
3
It’s a good idea to work with a primarycare physician. He or she will learnyour health needs better than anyone— and you’ll get the best care.
Here’s an easy-to-useHMO health benefitsplan from Aetna. Yousee your primary caredoctor, and you neverhave to file claimforms!
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S T E P # 1 :
Choose a PCP■ A primary care physician (PCP) is a doctor
you go to first. He or she can learn aboutyour health and help you manage it.
■ You can choose any PCP from the Aetnanetwork — it’s your choice. Plus, you’llfeel good knowing that anyone youchoose meets our standards.
■ Choosing a doctor is a personal decision.That’s why each member of your familycan have his or her own PCP.
■ You can change your PCP anytime. Call Member Services at the number on your ID card. Or visit our AetnaNavigator® member website atwww.aetna.com/statenj.
■ You must choose a PCP and see networkproviders to receive benefits through thisplan.
S T E P # 2 :
Visit your PCP for care■ Go to your PCP for checkups whenever
you are sick or hurt.
■ Your PCP will help you decide if youneed care from another doctor. If so,your PCP will give you a referral.
■ Sometimes you may need care thatrequires approval from Aetna beforeyou get it. Your PCP and othernetwork doctors will get this approvalfor you.
It’s as simple as this:
A primary doctor will guide your way
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A primary doctor will guide your wayS T E P # 3 :
Pay your copay■ When you visit your PCP or a specialist,
you pay a copay. This is a flat dollaramount you pay during your visit.
■ Your plan design and benefits summarylists your covered services and yourcopay amount.
Feel good about yourhealth care decisions. Ouronline services can help.
Find a doctor, fast!With our DocFind® online directory, you canlook for a doctor by specialty and location.Need to find a pediatrician near home? How about a surgeon who works with anearby hospital? All the information is there —plus maps and directions to the doctor’s office. You can even look for doctors who speak your language.
Manage your healthwith our members-onlywebsite.Need to learn the average cost of amedical procedure or service? Need toreplace an ID card? It’s easy with our secure Aetna Navigator member website at www.aetna.com/statenj.
■ Compare hospitals in your area oranywhere in the country.
■ See medical costs.
■ Help yourself stay well by makinghealthy changes to your lifestyle.
■ Read health information from Harvard Medical School.
■ Look through our online encyclopediafor information about hundreds ofhealth conditions.
Visit Aetna Navigatortoday, or take the FREEtour.
To take a tour of Aetna Navigator, go to www.aetna.com/statenj and click on Member Resources and then onNavigator. Once on the home page, click on take a tour to learn more.
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It’s easier to make gooddecisions about yourhealth when you havethe right information.
Have a health question inthe middle of the night?Contact our Informed Health® Line, anytime,24/7. Registered nurses are there to help. They can give you the information you needto work with your doctor. Then you can make health care decisions. Just call, toll free,1-800-556-1555.
While only your doctor can diagnose,prescribe or give medical advice, InformedHealth Line nurses can offer information on more than 5,000 health topics. Alwaysconsult your doctor first with questions orconcerns about your health care needs.
The smart way to learnabout your health —Aetna SmartSourceSM.Getting the right information is important to getting the care that’s right for you. Nowthere’s a tool that locates just what you need to make important decisions about your health.
It’s called Aetna SmartSource, and it willchange the way you research conditions,symptoms and more. Unlike most searchengines and general health websites, AetnaSmartSource delivers information that’sspecific to you based on where you live, your selected Aetna health plan and otherinformation.
Simple Steps To AHealthier Life®
Take the first step. It’sSimple. It’s for your health.
Simple Steps To A Healthier Life is apersonalized online health and wellnessprogram that makes it easy for you to helpimprove or maintain your health in ways thatfit your lifestyle. It can help you eat better,lose weight, get in shape, relieve stress andmore — in simple steps, at your own pace.Simple Steps To A Healthier Life is convenient,secure and can be accessed from home orwork. Best of all, it’s offered at no additionalcost to you.
The program starts with a Personal HealthRisk Assessment (HRA). The online Health RiskAssessment is a secure questionnaire that canhelp you identify some of your health needs.After you complete the assessment, you willreceive easy-to-understand Health Reportsand a one-page Health Summary. You canprint the Health Summary and share it withyour doctor or other health care professional.
Once you become an Aetna member, you can access Simple Steps To A Healthier Lifethrough www.aetna.com/statenj. Click onMember Resources, and then Simple Steps To A Healthier Life.
Aetna programs and resources to keep you healthy
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The New Jersey State HealthBenefits Program and SchoolEmployees’ Health BenefitsProgram include programs fordisease management, behavioralhealth and maternity, plus yourvery own online Personal HealthRecord, at no cost to you.
Support like neverbefore. Aetna HealthConnectionsSM diseasemanagement program
Reach your own level ofgood health.
Not everyone can be perfectly healthy. But even with an ongoing health condition,you can reach your own level of good health.Our disease management program can help.In this program, you can learn how to:
■ Get the treatment and preventive care youneed
■ Understand and follow your doctor’streatment plan
■ Better manage your ongoing conditions
■ Make changes to reach your personalhealth goals
■ Identify and manage your risks for otherconditions
You get this program as part of your Aetnahealth plan. There’s nothing extra to pay, andparticipation is up to you.
■ Get support from nurses for a healthier you
■ Our nurses and clinicians can support youeven if you have more than one condition.
You get this support all in one program, and you get:
— Educational materials mailed to you
— Online resources you can use anytime
— Nurse case management if you’re at high risk
— State-of-the-art technology that looksout for your health and safety
Support for more than 34conditions, including:
■ Diabetes
■ Gastrointestinal
■ Neurological
■ Orthopedic
■ Oncology
■ Vascular
■ And many others
No more healthinformation scavengerhuntsWith just one search, Aetna SmartSourcegives you relevant information to makeimportant decisions about caring for yourhealth needs. Simply enter a condition orsymptom.
Aetna SmartSource does the work foryou, scanning our vast resources to bringyou doctors in your local area whospecialize in treating your condition —and who participate in your health plan.
Be smart! Let AetnaSmartSource showyou what you need to know about yourhealth■ Commonly prescribed medications and
treatment options associated with yourcondition
■ Estimated health care costs
■ Aetna programs and discounts thatmay help you manage your healthneeds
■ Easy-to-understand health articles andtips
Aetna programs and resources to keep you healthy
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How our program can workfor you
As an example, let’s say you have diabetes.You may contact us to join. Or, we maycontact you to see if you want help managingyour health issues.
Our nurses can then:
■ Teach you about, and send you informationon, diabetes
■ Give you online resources to use anytime
■ Review the treatment plan and themedications your doctor gives you
■ Explain possible side effects and answeryour questions
■ Give you our 24-hour, toll-free diseasemanagement phone number
■ Work with you over time to help you meetyour goals for managing diabetes and otherhealth conditions
Each time you speak with a nurse, you willreceive a letter. The letter will list the pointsyou discussed and steps you decided to takebetween doctor visits. Our support team canhelp you learn how to help protect yourselffrom future health problems.
Give your baby a healthystart. Beginning Right®Maternity Program.
Our Beginning Right maternity programcomes with your Aetna health plan. Use itthroughout your pregnancy and after yourbaby is born. Learn what’s best for a healthypregnancy. Receive educational materials on:
■ Prenatal care
■ Signs of preterm labor
■ What to expect before and after delivery
■ Newborn care
■ And more
Take our pregnancy risk survey. Find out if youhave any health conditions or risk factors thatcould affect your pregnancy. You’ll get a smallgift (while supplies last) if you take the surveyby your 16th week of pregnancy.
If you are identified as being “at risk” or“high risk,” you’ll receive two follow-up callsafter delivery. Your nurse case manager willcheck in to see if you and your baby are doingwell. We can also do an initial screening fordepression and give you even more support if needed. We have nurses and other healtheducators who speak English and Spanish.Our translation service offers help in over 170languages. Plus, you can receive programmaterials in English and Spanish.
The more you know, the better chance youhave for good health — for you and yourbaby.
Go online and learn moreabout women’s health.
Go to Aetna Women’s Health online athttp://womenshealth.aetna.com forinformation on pregnancy and baby care, as well as
■ Reproductive health
■ Menopause
■ Breast health
■ Heart health
■ Migraines
■ Depression
Our Behavioral HealthProgram — finding peace of mind
When life becomes difficult to deal with,it’s good to know Aetna BehavioralHealth is there for you. Our behavioralhealth case management and diseasemanagement programs offer the supportyou and your loved ones need. Throughthem, we’ll coordinate behavioral healthand wellness services to be sure that youand your doctors use your benefits to thefullest. We offer programs to membersand their loves ones who have:
■ Combined medical and behavioralhealth conditions
■ Symptoms of depression
■ Anxiety disorders, such as generalizedanxiety, panic disorder, and post-traumatic stress syndrome
Members who complete these programshave been shown to have significantsymptom relief and improvement in theiroverall health. To learn more about ourbehavioral health specialty programs, logon to www.aetnabehavioralhealth.com.
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You don’t have to be rich or famous to makehistory. As an Aetna member, you can makehistory by putting your Personal Health Recordto work for you. This secure, private, onlineresource makes it easy for you to view, accessand manage your health information — andshare it with your doctors.
How it works
When you access your Personal HealthRecord, you will see that much of yourmedical history is already included. Then, it’seasy to enter more information to create acomprehensive picture of your overall health.Use it to track your health events, print a copyto help you fill out medical forms, and share itwith your doctor. Make history with Aetna!
How your PersonalHealth Record can help you
With this resource, it’s easyto:
Keep your healthinformation in a single place.And it’s always available foryou to access in anemergency.
Share your history with your doctor. Beforedoctor visits, print your detailed HealthSummary and take it with you to provide yourdoctors with a more comprehensive view ofyour health. Maintain or even improve yourhealth. Based on your health profile, providedby insurance claims and information you enteryourself, the Personal Health Record generatespersonalized health-related alerts andreminders that can help you address yourhealth needs in a timely manner.
Make HistorySM
Your medical history online . . . in one secure location.
Your health information, onesecure location
With your user name and password, youcontrol who sees your information. You canshare it as you see fit. The Health Summary isyour health “home page.” It’s the best placeto see an overview of your health information.You can decide what’s in it and what youshare with doctors and specialists.
Who has access?
Employees and covered family membershave separate Personal Health Records.As the subscriber of your health plan, youcan access and add information to thePersonal Health Record of any covereddependents under age 18.
Once you’re an Aetna member, you canaccess your Personal Health Recordthrough Aetna Navigator, located atwww.aetna.com/statenj. Click onMember Resources, Navigator, andthen Personal Health Record.
Who said nothing in life is free? Enroll in oneof our health benefit plans and get — at noadded cost — the Aetna extras! Our discountprograms and services are your ticket to the small luxuries that can keep you happyand healthy.
Save right away on:
■ Fitness club memberships
■ Treadmills and elliptical trainers
■ LASIK surgery
■ Massage therapy
■ Colored contact lenses
■ And more!
Regular exercise can help you stay healthy and can make you look and feel better. With our Fitness Program, you can savemoney, too! It’s easy to get started onceyou’ve enrolled with Aetna.
Good health can mean more than visiting the doctor
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Good health can mean more than visiting the doctor A fitness program for
your body … and budget
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More reasons to join ourFitness Program■ Flexible memberships, with month-to-
month and 48-week options
■ Convenient billing through your bankaccount or major credit card
■ Guest privileges at participating clubs whentraveling for 48-week members
■ Savings on home exercise equipment and videos
■ At-home weight loss and one-on-onehealth coaching programs§.
*Membership to a club of which you are a current member is not available. Membership also may not be available to a club if you have been a member of that clubwithin the past 12 months.
†GlobalFit website, www.globalfit.com/fitness, 1/07.
‡Guest passes not available at all clubs.§Provided by WellCall, Inc.
Pick a club — join a clubEnjoy preferred rates on fitness clubmemberships in the GlobalFit™ network.*With over 2,000 locations†, it’s easy to findone near you. Features like a FREE guest pass‡
and flexible membership options can help youget started. Here’s how…
Step #1: Visit www.globalfit.com/fitnessfor a list of participating clubs.
Step #2: Choose a club and follow directionsfor a FREE guest pass (available at most clubs).It’s your sneak peek at the club culture,services and equipment.
Step #3: Enroll online, or call GlobalFit toll free at 1-800-298-7800.
Did
you
kno
w?
A daily dose ofexercise keeps yourheart healthy, yourbones strong — and may help you geta better night’s sleep.
See your way to bigger savings!
You’ll pay less for eyeglasses, contact lenses,cleaning solutions, and even LASIK eye surgery.You’ll even save on specialty items not typicallycovered by insurance — like snazzy eyeglasschains, designer frames, sunglasses andcolored contact lenses.
Enroll with Aetna, and use your discount eachtime you visit a participating store. Just book,browse and save!
■ Book — Make an appointment or go to aparticipating store. Choose from a largenetwork of providers, including participatingSears Optical, Target Optical®, JCPenney®
Optical, LensCrafters®, Pearle Vision®, andthousands of independent optometrists and ophthalmologists.
■ Browse — Choose from fashionableframes and the latest in lens technology.
■ Save — Show your Aetna ID card forinstant savings.
Save on LASIK surgeryLASIK surgery just got more affordable. You’llsave up to 15%. Plus, you’ll get education, aninitial screening and follow-up care — all forone discounted price. The initial consultation is always free. Call 1-800-422-6600.
This is a brief listing of the savings you can receivethrough Aetna VisionSM Discounts.*
PRODUCT OR SERVICE WHAT YOU’LL PAY
Eye Exams for Plans Refer to your health benefits plan That Cover Eye Exams documents for coverage details.
Eye Exams for Plans That Do Not Cover Eye Exams■ Comprehensive eye exam $42■ Standard contact lenses fit & follow-up $40 (plus $42 exam fee)■ Specialty contact lenses fit & follow-up $10 off retail (plus $42 exam fee)
(e.g. toric, bifocal, gas-permeable)
Lenses per Pair (uncoated plastic)■ Single Vision $40■ Bifocal $60■ Trifocal $80■ Standard Progressive (no-line bifocal) $120
Eyeglass Frames (retail prices) 40% off retail prices
Lens Options per Pair (add to lens price above)■ Standard polycarbonate (includes ultraviolet (UV) $40
coating and scratch-resistant coating)■ Scratch-resistant coating $15■ UV coating $15■ Solid or gradient tint $15■ Standard antireflective coating $45■ Glass 20% off retail■ Photochromic Glass 20% off retail
Contact LensesGet a 15% discount (5% on disposables) off retail prices.
Mail-Order Contact Lens Replacement Program Call 1-800-391-LENS (5367) to order replacement contact lenses. (Mail-order contact prices are not subject to the discounts received at participating locations.)
Additional Vision-related ItemsVisit any participating location to receive a 20% discount off retail prices.
LASIK ProcedureSave up to 15% off the surgeon’s fee through the U.S. Laser Network.
*EyeMed Services and Compensation Schedule, 7/09. Prices are subject to change.
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A vision program for eye-opening savings
Few people travel the same path to goodhealth. That’s why the Aetna Natural Productsand ServicesSM program delivers savings oncomplementary health services and naturalproducts through American Specialty HealthNetworks, Inc., a recognized leader in thismarket.
It’s a smart way to save on items not typicallycovered by insurance.
Massage therapy
Lower your stress, improve your health, relieveyour aching muscles — and save.
Acupuncture
Pinpoint your pain or stress with this 5,000-year-old therapy, for less.
Chiropractic care
Get realigned with savings on regularchiropractic visits.
Dietetic counseling
Eat healthier. Look leaner. Feel better.Registered dieticians can show you how.
Natural products
Get a discount on your daily dose of over-the-counter vitamins, aromatherapy, yogaequipment, nutritional and healthsupplements, and more.
A complementary health care programto relax, recharge and save!
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Hear the world clearly with Aetna HearingSM
Discounts. You save on the latest hearing aidstyles and technologies. You also get 40% offthe retail price of hearing exams and hearingaid services.
It’s not insurance, so there’s no need forreferrals or claims. You’ll get:
■ Savings on many styles, from completecanal to behind-the-ear aids
■ Savings on new technology, includingprogrammable and digital instruments
■ Discounts on hearing aid repairs
■ Free follow-up service for one year
■ Over 1,500 locations nationally*
A hearing discount programto hear the world clearly
Remember, if your health benefits or healthinsurance plan coverhearing aids or exams,follow your plan’sinstructions first.
Typical prices for hearing aids
Here are the typical prices you’ll pay for hearing aids — after the applied discount.* Visit www.aetna.com or call HearPO customerservice (weekdays, 9 a.m. to 6 p.m. ET) at 1-888-HEARING (1-888-432-7564) for more information.
Level Behind the Ear In the Ear In the Canal Complete in the Canal
Economy $549 – $1,295 $549 – $1,195 $995 – $1,195 $995 – $1,295
Entry Level $1,195 – $1,795 $1,295 – $1,595 $1,295 – $1,595 $1,295 – $1,595
Mid Level $1,595 – $1,995 $1,595 – $1,895 $1,595 – $1,995 $1,595 – $2,295
Upper Level $1,995 – $2,595 $1,895 – $2,495 $1,995 – $2,595 $1,995 – $2,695
* HearPO website, www.hearpo.com/aetna, 1/09. The most appropriate hearing instrument will be selected based on your needs. These discounts apply to all manufacturers, but the actualdiscount you receive will vary based on the manufacturer and the hearing aid.
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Looking to lose weight and feel better? Our weight management discount programcan help.
You and your eligible family members cansave on weight-loss programs and productsfrom one of the largest weight managementfirms worldwide — Jenny Craig®. You’ll get asensible weight loss plan, one-on-one weeklyconsultations and discounts on weight lossproducts that fit your lifestyle.
You’ll start with a FREE 30-day membership.Then, join a program and save!
■ Get 30% off an OnTrack 6-month (Gold) or 12-month (Platinum) membership.*
■ Get 15% off a Jenny Rewards 12-month membership.**
You also get:
■ Personalized menus
■ Tailored activity planning
■ Free unlimited use of Jenny Craig tools
■ Flexible programs to fit your schedule
■ And more
It’s easy to get started:
1. Enroll in an Aetna plan.
2. Register for your secure Aetna Navigator member website.
3. Print your personalized registration coupon.
4. Call 1-800-597-JENNY to find the centre nearest you.
5. Bring your registration coupon and Aetna ID to get your free consultation.
* Offers good only at participating centres and through Jenny Direct At-Home. Additional cost for all food purchases. Discounts apply to membership fee only.
** Additional weekly food discounts will grow throughout the year, based on active participation.
A weight management discount programto look and feel better
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More savings for you!■ Save on Waterpik® sonic toothbrushes and
Epic Dental products like gum, toothpastes,and mouth rinses with xylitol — a naturalsweetener designed to stop tooth decay.
■ Save 10% on gift certificates of $100 ormore from SpaWish® that can be used atover 1,000 spas nationally.
■ Subscribe to www.zagat.com and get30% off your membership. You’ll getratings on restaurants, hotels, movies,attractions and more.
■ Get a personalized eating plan and save up to 25% on eDiets® membership dues.
■ Save on newsletters and books from thewww.mayoclinic.com bookstore.
Get fit, stay well and save!
What’s more important than your health?Start saving today on services and productsthat can help you stay well. And takeadvantage of other offers that respond toyour special needs.
They’re the Aetna extras that are all here foryou when you enroll in one of our medicalbenefit plans. Use them often. And use themin good health.
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Plan BenefitsYour plan of benefits will be determined by your plan sponsor.Covered services include most types of treatment provided byprimary care physicians, specialists and hospitals. However, thehealth plan does exclude and/or include limits on coverage forsome services, including but not limited to, cosmetic surgery andexperimental procedures. In addition, in order to be covered, allservices, including the location (type of facility), duration and costsof services, must be medically necessary as defined below and asdetermined by Aetna*. The information that follows providesgeneral information regarding Aetna health plans. For a completedescription of the benefits available to you, including proceduresto follow, exclusions and limitations, refer to your specific plandocuments, which may include the Schedule of Benefits,Certificate of Coverage, Group Agreement, Group InsuranceCertificate, Group Insurance Policy and any applicable riders andamendments to your plan.
Member Cost SharingCost sharing refers to the portion of medical services that you payout of your own pocket. Refer to your plan documents to seewhich of the following cost-sharing provisions apply to your plan:
■ Copay – This may be a flat fee that you pay directly to thehealth care provider at the time of service.
■ Coinsurance – This is a percentage of the fees that you must paytoward the cost of some covered medical expenses. Your healthcare provider will bill you for this amount.
■ Calendar Year Deductible – The amount of covered medicalexpenses you pay each calendar year before benefits are paid.There is a calendar-year deductible that applies to each person.
* Aetna is the brand name used for products and services provided by one ormore of the Aetna group of subsidiary companies. The companies that offer,underwrite or administer benefits coverage include Aetna Health Inc., AetnaHealth of the Carolinas Inc., Aetna Health Insurance Company and/or AetnaLife Insurance Company.
■ Inpatient Hospital Deductible – The amount of coveredinpatient hospital expenses you pay for each hospitalconfinement before benefits are paid. This deductible is in addition to any other copayments or deductibles underyour plan.
■ Emergency Room Deductible – The amount of coveredhospital emergency room expenses you pay each year before benefits are paid. A separate hospital emergencyroom deductible applies to each visit by a person to ahospital emergency room unless the person is admitted tothe hospital as an inpatient within 24 hours after a visit to a hospital emergency room.
Your Primary Care PhysicianCheck your plan documents to see if your plan requires you toselect a primary care physician (PCP). If a PCP is required, youmust choose a doctor from the Aetna network. You can lookup network doctors in a printed Aetna Physician Directory, orvisit our DocFind® directory at www.aetna.com. If you do nothave Internet access and would like a printed directory, pleasecontact Member Services at the toll-free number on your IDcard and request a copy.
You may choose a different PCP for each member of yourfamily. When you enroll, indicate the name of the PCP youhave chosen on your enrollment form. Or, call Member Servicesafter you enroll to tell us your selection. The name of your PCPwill appear on your Aetna ID card. You may change yourselected PCP at any time. If you change your PCP, you willreceive a new ID card.
Your PCP can provide primary health care services as well ascoordinate your overall care. You should consult your PCPwhen you are sick or injured to help determine the care that isneeded. If your plan requires referrals, your PCP should issue areferral to a participating specialist or facility for certain services.(See Referral Policy for details.)
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Important Disclosure Information
Aetna Health Network OnlySM, HMO, Aetna Open Access® HMO, Aetna Health Network OptionSM,QPOS® and Aetna Choice® POS Plans.
State mandates do not apply to self-funded plans governed by ERISA. If you are unsure if your plan isself-funded and/or governed by ERISA, see your benefits administrator. Specific plan documentssupersede general disclosures contained within, as applicable.
Referral PolicyCheck your plan documents to see if your plan requires PCPreferrals for specialty care. Your plan documents will also list anydirect access benefits that do not require referrals. If referrals arerequired, you must see your PCP first before visiting a specialistor other outpatient provider for nonemergency or nonurgentcare. Your PCP will issue a referral for the services needed.
If you do not get a referral when a referral is required, you mayhave to pay the bill yourself, or the service will be treated asnonpreferred if your plan includes out-of-network benefits.Some services may also require prior approval by us. See thePrecertification section and your plan documents for details.
The following points are important to remember regardingreferrals.
■ The referral is how your PCP arranges for you to be covered atthe in-network benefit level for necessary, appropriatespecialty care and follow-up treatment.
■ You should discuss the referral with your PCP to understandwhat specialist services are being recommended and why.
■ If the specialist recommends any additional treatments or testsbeyond those referred by the PCP, you may need to getanother referral from your PCP before receiving the services.
■ Except in emergencies, all inpatient hospital services require aprior referral from your PCP and prior authorization by Aetna.
■ Referrals are valid for one year as long as you remain aneligible member of the plan; the first visit must be within 90days of referral issue date.
■ In plans without out-of-network benefits, coverage for servicesfrom nonparticipating providers requires prior authorization byAetna in addition to a special nonparticipating referral fromthe PCP. When properly authorized, these services are fullycovered, less the applicable cost sharing.
■ The referral (and a precertification, if required) provides that,except for applicable cost sharing (that is, copays, coinsuranceand/or deductibles), you will not have to pay the charges forcovered expenses, as long as the individual seeking care is amember at the time the services are provided.
Direct AccessUnder Aetna Open Access HMO and Aetna Choice POS plansyou may directly access participating providers without a PCPreferral, subject to the terms and conditions of the plan and costsharing requirements. Participating providers will be responsiblefor obtaining any required preauthorization of services fromAetna. Refer to your specific plan documents for details.
Aetna Choice POS and QPOS plans have direct-access benefits.Direct-access benefits allow you to directly access participatingproviders and nonparticipating providers without a PCP referral,subject to additional cost sharing requirements. Even so, youmay be able to reduce your out-of-pocket expenses considerablyby using participating providers. Refer to your specific planbrochure for details.
If your plan does not specifically cover direct-access benefits(self-referred or nonparticipating provider benefits) and you godirectly to a specialist or hospital for nonemergency ornonurgent care without a referral, you must pay the bill yourselfunless the service is specifically identified as a direct-accessbenefit in your plan documents.
Direct Access Ob/Gyn ProgramThis program allows female members to visit, without a referral,any participating obstetrician or gynecologist for a routine well-woman exam, including a breast exam, mammogram and a Pap smear, and for obstetric or gynecologic problems.Obstetricians and gynecologists may also refer a woman directly to other participating providers for covered obstetric or gynecologic services. All health plan preauthorization andcoordination requirements continue to apply. If your Ob/Gyn ispart of an Independent Practice Association (IPA), a PhysicianMedical Group (PMG), an Integrated Delivery System (IDS) or asimilar organization, your care must be coordinated through theIPA, the PMG or similar organization and the organization mayhave different referral policies.
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PCP Referrals PrecertificationProduct Required? Required? Required?
HMO Yes Yes Yes
Aetna Open Access HMO Encouraged No Yes
Health Network Only Encouraged No Yes
QPOS Yes Yes Yes
Aetna Choice POS Encouraged No Yes
PrecertificationSome health care services, like hospitalization and certainoutpatient surgery, require “precertification.” This means theservice must be approved by Aetna before it will be coveredunder the plan. Check your plan documents for a complete list of services that require this approval. When reviewing aprecertification request, we will verify your eligibility andmake sure the service is a covered expense under your plan. We also check the cost-effectiveness of the service and we maycommunicate with your doctor if necessary. If you qualify, wemay enroll you in one of our case management programs andhave a nurse call to make sure you understand your upcomingprocedure.
When you visit a doctor, hospital or other provider thatparticipates in the Aetna network, someone at the provider’soffice will contact Aetna on your behalf to get the approval.
If your plan allows you to go outside the Aetna network ofproviders, you will have to get that approval yourself. In thiscase, it is your responsibility to make sure the service isprecertified, so be sure to talk to your doctor about it. If you do not get proper authorization for out-of-network services, you may have to pay for the service yourself.
You cannot request precertification after the service isperformed. To precertify services, call the number shown on your Aetna ID card.
Health Care Provider NetworkAll hospitals may not be considered Aetna participating providersfor all the services that you need. Your physician can contactAetna to identify a participating facility for your specific needs.Certain PCPs are affiliated with IDSs, IPAs or other providergroups. If you select one of these PCPs you will generally bereferred to specialists and hospitals within that system,association or group (“organization”). However, if your medicalneeds extend beyond the scope of the affiliated providers, youmay request coverage for services provided by Aetna networkproviders that are not affiliated with the organization. In order tobe covered, services provided by network providers that are notaffiliated with the organization may require prior authorizationfrom Aetna and/or the IDS or other provider groups. You shouldnote that other health care providers (e.g. specialists) may beaffiliated with other providers through organizations.
For up-to-date information about how to locate inpatient andoutpatient services, partial hospitalization and other behavioralhealth care services, please visit our DocFind directory atwww.aetna.com. If you do not have Internet access and wouldlike a printed provider directory, please contact Member Servicesat the toll-free number on your Aetna ID card and request acopy.
Advance DirectivesThere are three types of advance directives:■ Durable power of attorney – appoints someone you trust to
make medical decisions for you.
■ Living will – spells out the type and extent of care you want toreceive.
■ Do-not-resuscitate order – states that you don’t want to begiven CPR if your heart stops or be intubated if you stopbreathing.
You can create an advance directive in several ways:
■ Get an advance medical directive form from a health careprofessional. Certain laws require health care facilities thatreceive Medicare and Medicaid funds to ask all patients at thetime they are admitted if they have an advance directive. Youdon’t need an advance directive to receive care. But we arerequired by law to give you the chance to create one.
■ Ask for an advance directive form at state or local offices onaging, bar associations, legal service programs, or your localhealth department.
■ Work with a lawyer to write an advance directive.
■ Create an advance directive using computer software designedfor this purpose.
■ If you are not satisfied with the way Aetna handles advancedirectives, you can file a complaint with your Medicare StateCertification Agency. Visit www.medicare.gov forinformation on specific state agencies or call 1-800-MEDICARE (1-800-633-4227) (TTY/TDD: 1-877-486-2048).
Source: American Academy of Family Physicians. AdvancedDirectives and Do Not Resuscitate Orders. January 2009.Available at http://familydoctor.org/003.xml?printxml.Accessed February 20, 2009.
Transplants and Other Complex ConditionsOur National Medical Excellence Program® and other specialtyprograms help you access covered services for transplants andcertain other complex medical conditions at participating facilitiesexperienced in performing these services. Depending on theterms of your plan of benefits, you may be limited to only thosefacilities participating in these programs when needing atransplant or other complex condition covered.
Note: There are exceptions depending on state requirements.
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Emergency CareIf you need emergency care, you are covered 24 hours a day, 7days a week, anywhere in the world. An emergency medicalcondition is one manifesting itself by acute symptoms of sufficientseverity such that a prudent layperson, who possesses averageknowledge of health and medicine, could reasonably expect theabsence of immediate medical attention to result in seriousjeopardy to the person's health, or with respect to a pregnantwoman, the health of the woman and her unborn child.
Whether you are in or out of an Aetna service area, we simplyask that you follow the guidelines below when you believe youneed emergency care.
■ Call the local emergency hotline (ex. 911) or go to the nearestemergency facility. If a delay would not be detrimental to yourhealth, call your doctor or PCP. Notify your doctor or PCP assoon as possible after receiving treatment.
■ If you are admitted to an inpatient facility, you or a familymember or friend on your behalf should notify your doctor,PCP or Aetna as soon as possible.
What to Do Outside Your Aetna Service AreaIf you are traveling outside your Aetna service area or if you are astudent who is away at school; you are covered for emergencyand urgently needed care. Urgent care may be obtained from aprivate practice physician, a walk-in clinic, an urgent care center oran emergency facility. Certain conditions, such as severe vomiting,earaches, sore throats or fever, are considered "urgent care"outside your Aetna service area and are covered in any of theabove settings.
If, after reviewing information submitted to us by the providerthat supplied care, the nature of the urgent or emergencyproblem does not qualify for coverage, it may be necessary toprovide us with additional information. We will send you anEmergency Room Notification Report to complete, or a MemberServices representative can take this information by telephone.
Follow-up Care after EmergenciesAll follow-up care should be coordinated by your PCP. Follow-upcare with nonparticipating providers is only covered with a referralfrom your PCP and prior authorization from Aetna. Whether youwere treated inside or outside your Aetna service area, you mustobtain a referral before any follow-up care can be covered. Sutureremoval, cast removal, X-rays and clinic and emergency roomrevisits are some examples of follow-up care.
After-Hours CareYou may call your provider’s office 24 hours a day, 7 days a weekif you have medical questions or concerns. You may also considervisiting participating Urgent Care facilities. See your plandocuments for cost-sharing provisions for urgent care services.
Behavioral Health NetworkBehavioral health care services are managed by Aetna. As aresult, Aetna is responsible for making initial coveragedeterminations and coordinating referrals to the Aetna providernetwork. As with other coverage determinations, you mayappeal adverse behavioral health care coverage determinationsin accordance with the terms of your health plan.
The type of behavioral health benefits available to you dependson the terms of your health plan and state law. If your healthplan includes behavioral health services, you may be covered formental health conditions and/or drug and alcohol abuseservices, including inpatient and outpatient services, partialhospitalizations and other behavioral health services. You candetermine the type of behavioral health coverage availableunder the terms of your plan and how to access services bycalling the Aetna Member Services number listed on your IDcard.
If you have an emergency, call 911 or your local emergencyhotline, if available. For routine services, access coveredbehavioral health services available under your health plan bythe following methods:
■ Call the toll-free Behavioral Health number (where applicable)listed on your ID card or, if no number is listed, call theMember Services number listed on your ID card for theappropriate information.
■ Where required by your plan, call your PCP for a referral tothe designated behavioral health provider group.
■ When applicable, an employee assistance or studentassistance professional may refer you to your designatedbehavioral health provider group.
You can access most outpatient therapy services without areferral or preauthorization. However, you should first consultMember Services to confirm that any such outpatient therapyservices do not require a referral or preauthorization.
Behavioral Health Provider Safety DataAvailableFor information about our Behavioral Health provider networksafety data, visit www.aetna.com/docfind and select the “Getinfo on Patient Safety and Quality” link. If you do not haveInternet access, you may call Member Services at the toll-freenumber shown on your Aetna ID card to request a printed copyof this information.
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Behavioral Health Depression PreventionProgramsAetna Behavioral Health offers two prevention programs for ourmembers: Perinatal Depression Education, Screening and TreatmentReferral Program, also known as Beginning Right® DepressionProgram, and Identification and Referral of Adolescent MembersDiagnosed With Depression Who Also Have Comorbid SubstanceAbuse Needs. For more information on either of these preventionprograms and how to use the programs, ask Member Services forthe phone number of your local Care Management Center.
How Aetna Pays In-Network ProvidersAll the providers in our network directory are independent. They arefree to contract with other health plans. Providers join our networkby signing contracts with us. Or they work for organizations thathave contracts with us. We pay network providers in many differentways. Sometimes we pay a rate for a specific service and sometimesfor an entire course of care (for example, a flat fee for a pregnancywithout complications). In certain circumstances, some providers arepaid a pre-paid amount per month per Aetna member (capitation).We may also provide additional incentives to reward physicians fordelivering cost-effective quality care.
We pay some network hospitals by the day (per diem) and we payothers in a different way, such as a percentage of their standardbilling rates. We encourage you to ask your providers how they arepaid for their services.
How Aetna Pays Out-of-Network ProvidersSome of our plans pay for services from providers who are not inour network. Many plans pay for services based on what is calledthe “reasonable,” “usual and customary” or “prevailing” charge.Other plans pay based on our standard fees for care received from anetwork provider, or based on a percentage of Medicare’s fees.When we pay less than what your provider charges, yourprovider may require you to pay the difference. This is trueeven if you have reached your plan’s out-of-pocket maximum.Here is how we figure out what we will pay for each type of plan.
Prevailing Charge PlansStep 1: We review the data.We get information from Ingenix, which is owned by UnitedHealthCare. Health plans send Ingenix copies of claims for servicesthey received from providers. The claims include the date and placeof the service, the procedure code, and the provider’s charge.Ingenix combines this information into databases that show howmuch providers charge for just about any service in any zip code.
Step 2: We calculate the portion we pay.For most of our health plans, we use the 80th percentile to calculatehow much to pay for out-of-network services. Payment at the 80thpercentile means 80 percent of charges in the database are thesame or less for that service in a particular zip code.
If there are not enough charges (less than 9) in the databases for aservice in a particular zip code, we may use “derived charge data”instead. “Derived charge data” is based on the charges forcomparable procedures, multiplied by a factor that takes intoaccount the relative complexity of the procedure that wasperformed. We also use derived charge data for our student healthplans and Aetna Affordable Health Choices® plans.
We also may consider other factors to determine what to pay ifa service is unusual or not performed often in your area. Thesefactors can include:
■ The complexity of the service
■ The degree of skill needed
■ The provider’s specialty
■ The prevailing charge in other areas
■ Aetna’s own data
Step 3: We refer to your health plan.We pay our portion of the prevailing charge as listed in yourhealth plan. You pay your portion (called “coinsurance”) andany deductible.
For example, your out of network doctor charges $120 for anoffice visit. Your plan covers 70 percent of the “reasonable,”“usual and customary” or “prevailing” charge. Let's say theprevailing charge is $100. And let's say you already met yourdeductible. Aetna would pay $70. You would pay the other$30. Your doctor may also bill you for the $20 differencebetween the prevailing charge ($100) and the billed charge($120). In this case, your doctor could bill you for a total of $50.
The Prevailing Charge DatabasesThe New York State Attorney General (NYAG) investigated theconflicts of interest related to the ownership and use of Ingenixdata. Under an agreement with the NYAG, UnitedHealth Groupagreed to stop using the Ingenix databases when anindependent database (not owned by a health insurer) iscreated. In a separate agreement with NYAG in January 2009,Aetna agreed to use this new database when it is ready. Wealso will work with the new database owner to create onlinetools to give you better information about the cost of your carewhen using providers outside our network.
Fee Schedule PlansStep 1: We compare the provider’s bill to our fee scheduleand your health plan.Your plan may say that we will pay the provider based on ourfee schedule for network doctors, or a certain percentage ofthat fee schedule, or a certain percentage of what Medicarepays. For example, your plan may say we pay 125 percent ofwhat we pay a network doctor for the same service.
Let’s say you have your appendix removed. Our network ratefor that surgery is $1,600. We multiply $1,600 by 125percent to get $2,000. We call this the “recognized” or“allowed” amount.
Step 2: We calculate the portion we pay.Your plan also says that you must pay “coinsurance.” This isyour share of the “recognized” or ”allowed” amount.
For example, your share may be 30 percent. In that case, wepay 70 percent of the $2,000 allowed amount, which is$1,400. You pay your provider your 30 percent coinsurance,which is $600. Your provider may also ask you to pay the$500 difference between the $2,500 bill and the $2,000“recognized” or “allowed” amount. In this case, yourprovider could bill you $1,100 in total.
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ExceptionsSome “prevailing charge" plans set the prevailing charge at adifferent percentile. For some claims (like those from hospitalsand outpatient centers) we may use other information anddata sources to determine the charge. And some of our planspay based on a different kind of fee schedule. Also, for somenon-participating providers we may pay based on othercontractual arrangements.
Our provider claims codes and payment policies may also affectwhat we pay for a claim. Aetna may use computer software(including ClaimCheck®) and other tools to take into accountfactors such as the complexity, amount of time needed andmanner of billing. The effects of these policies will be reflectedin your Explanation of Benefits documents.
How Aetna Pays for Out-of-Network BehavioralHealth BenefitsWe negotiate rates with psychiatrists, psychologists, counselorsand other appropriately licensed and credentialed behavioralhealth care providers to help you save money. We refer to theseproviders as being "in our network."
Technology ReviewWe review new medical technologies, behavioral healthprocedures, pharmaceuticals and devices to determine whichone should be covered by our plans. And we even look at newuses for existing technologies to see if they have potential. Toreview these innovations, we may:
■ Study published medical research and scientific evidence onthe safety and effectiveness of medical technologies
■ Consider position statements and clinical practice guidelinesfrom medical and government groups, including the federalAgency for Health Care Research and Quality
■ Seek input from relevant specialists and experts in thetechnology
■ Determine whether the technologies are experimental orinvestigational
You can find out more on new tests and treatments in ourClinical Policy Bulletins. See Clinical Policy Bulletins below formore information.
Medically Necessary"Medically necessary" means that the service or supply isprovided by a physician or other health care provider exercisingprudent clinical judgment for the purpose of preventing,evaluating, diagnosing or treating an illness, injury or disease orits symptoms, and that provision of the service or supply is:
■ In accordance with generally accepted standards of medicalpractice; and
■ Clinically appropriate in accordance with generally acceptedstandards of medical practice in terms of type, frequency,extent, site and duration, and considered effective for theillness, injury or disease; and
■ Not primarily for the convenience of you, or for the physician orother health care provider; and
■ Not more costly than an alternative service or sequence ofservices at least as likely to produce equivalent therapeutic ordiagnostic results as to the diagnosis or treatment of the illness,injury or disease.
For these purposes “generally accepted standards of medicalpractice” means standards that are based on credible scientificevidence published in peer-reviewed medical literature generallyrecognized by the relevant medical community, or otherwiseconsistent with physician specialty society recommendations andthe views of physicians practicing in relevant clinical areas and anyother relevant factors.
Clinical Policy BulletinsClinical Policy Bulletins (CPBs) describe our policy determinationsof whether certain services or supplies are medically necessary orexperimental or investigational, based on a review of currentlyavailable clinical information. Clinical determinations inconnection with individual coverage decisions are made on acase-by-case basis consistent with applicable policies.
Aetna CPBs do not constitute medical advice. Treating providersare solely responsible for medical advice and for your treatment.You should discuss any CPB related to your coverage or conditionwith your treating provider. While Aetna CPBs are developed toassist in administering plan benefits, they do not constitute adescription of plan benefits. Each benefit plan defines whichservices are covered, which are excluded, and which are subjectto dollar caps or other limits. You and your providers will need toconsult the benefit plan to determine if there are any exclusionsor other benefit limitations applicable to this service or supply.
CPBs are regularly updated and are therefore subject to change.You can find them online at www.aetna.com under “Members”and then “Health Coverage Information.” If you do not haveInternet access, please contact Member Services at the toll-freenumber on your ID card for information about specific ClinicalPolicy Bulletins.
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Utilization Review/Patient ManagementWe have developed a patient management program to assistin determining what health care services are covered underthe health plan and the extent of such coverage. Theprogram assists you in receiving appropriate health care andmaximizing coverage for those health care services. You canavoid receiving an unexpected bill with a simple call toMember Services. You can find out if your preventive careservice, diagnostic test or other treatment is a coveredbenefit — before you receive care — just by calling the toll-free number on your ID card. In certain cases, we reviewyour request to be sure the service or supply is consistentwith established guidelines and is a covered benefit underyour plan. We call this “utilization management review.”
We follow specific rules to help us make your health a topconcern:
■ Aetna employees are not compensated based on denialsof coverage.
■ We do not encourage denials of coverage. In fact, ourutilization review staff is trained to focus on the risks ofmembers not adequately using certain services.
Where such use is appropriate, our Utilization Review/PatientManagement staff uses nationally recognized guidelines andresources, such as The Milliman Care Guidelines® to guidethe precertification, concurrent review and retrospectivereview processes. To the extent certain UtilizationReview/Patient Management functions are delegated to IDSs,IPAs or other provider groups ("Delegates"), such Delegatesutilize criteria that they deem appropriate. UtilizationReview/Patient Management policies may be modified tocomply with applicable state law.Only medical professionals make decisions denying coveragefor services for reasons of medical necessity. Coverage denialletters for such decisions delineate any unmet criteria,standards and guidelines, and inform the provider and youof the appeal process. For more information concerningutilization management, you may request a free copy of thecriteria we use to make specific coverage decisions bycontacting Member Services. You may also visitwww.aetna.com/about/cov_det_policies.html to find ourClinical Policy Bulletins and some utilization review policies.Doctors or health care professionals who have questionsabout your coverage can write or call our PatientManagement department. The address and phone numberare on your ID card.
Concurrent ReviewConcurrent review is a review conducted while a patient isconfined on an inpatient basis. The concurrent review processassesses the necessity for continued stay, level of care, and qualityof care for members receiving inpatient services. All inpatientservices extending beyond the initial certification period will requireconcurrent review.
Discharge PlanningDischarge planning may be initiated at any stage of the patientmanagement process and begins immediately upon identificationof post-discharge needs during precertification or concurrentreview. The discharge plan may include initiation of a variety ofservices/benefits to be utilized by you upon discharge from aninpatient stay.
Retrospective Record ReviewRetrospective review is a review conducted after the patient hasbeen discharged from the hospital or facility. The purpose ofretrospective review is to retrospectively analyze potential qualityand utilization issues, initiate appropriate follow-up action basedon quality or utilization issues, and review all appeals of inpatientconcurrent review decisions for coverage of health care services.Our effort to manage the services provided to you includes theretrospective review of claims submitted for payment, and ofmedical records submitted for potential quality and utilizationconcerns.
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Complaints, Appeals and External ReviewThis Complaint Appeal and External Review process may not apply if your plan is self-funded. Contact your BenefitsAdministrator if you have any questions.
Filing a Complaint or AppealWe are committed to addressing your coverage issues,complaints and problems. If you have a coverage issue orother problem, call Member Services at the toll-free numberon your ID card or e-mail us from your secure AetnaNavigator® member website. Click on “Contact Us” afteryou log on. You can also contact Member Services atwww.aetna.com. If Member Services is unable to resolveyour issue to your satisfaction, it will be forwarded to theappropriate department for handling.
If you are dissatisfied with the outcome of your initialcontact, you may file an appeal. Your appeal will be decidedin accordance with the procedures applicable to your planand applicable state law. Refer to your plan documents fordetails regarding your plan's appeal procedure.
About Coverage DecisionsSometimes we receive claims for services that may not becovered by your health benefits plan. It can be confusing —even to your doctors. Our job is to make coverage decisionsbased on your specific benefits plan.
If a claim is denied, we’ll send you a letter to let you know. If you don’t agree you can file an appeal. To file an appeal,follow the directions in the letter that explains that yourclaim was denied. Our appeals decisions will be based onyour plan provisions and any state and federal laws orregulations that apply to your plan. You can learn moreabout the appeal procedures for your plan from your plandocuments.
External ReviewWe established an external review process to give you theopportunity of requesting an objective and timelyindependent review of certain coverage denials. Once theapplicable internal appeal process has been exhausted, youmay request an external review of the decision for thecoverage denial if: (a) you would be financially responsiblefor the cost of services; (b) the amount of the service(s) ismore than $500, and (c) is based on lack of medicalnecessity or on the experimental or investigational nature ofthe proposed service or supply. Standards may vary by state,and several states have external review processes that mayapply to your plan.
If a request meets the requirement for an external review, anIndependent Review Organization (IRO) will assign the caseto an external physician reviewer with appropriate expertisefor an independent decision in the area in question. After allnecessary information is submitted, an external reviewgenerally will be decided within 30 calendar days of therequest.
Expedited reviews are available when your physician certifiesthat a delay in service would jeopardize your health. Oncethe review is complete, the plan will abide by the decision ofthe external reviewer. The cost for the review will be borneby Aetna (except where state law requires you to pay a filingfee as part of the state mandated program).
Certain states mandate external review of additional benefitor service issues; some may require a filing fee. In addition,certain states mandate the use of their own external reviewprocess for medical necessity and experimental orinvestigational coverage decisions. These state mandates may not apply to self-funded plans.
For details about your plan's appeal process and theavailability of an external review process, visitwww.aetna.com to print an external review request form orcall the Member Services toll-free number on your ID card.You also may call your state insurance or health departmentor consult their website for additional information regardingstate mandated external review procedures.
Member Rights & ResponsibilitiesYou have the right to receive a copy of our Member Rightsand Responsibilities Statement. This information is availableto you at www.aetna.com/about/MemberRights. You canalso obtain a print copy by contacting Member Services atthe number on your ID card.
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Member ServicesTo file a complaint or an appeal, for additional informationregarding copayments and other charges, informationregarding benefits, to obtain copies of plan documents,information regarding how to file a claim or for any otherquestion, you can contact Member Services at the toll-freenumber on your ID card, or email us from your secure AetnaNavigator member website at www.aetna.com. Click on“Contact Us” after you log on.
Interpreter/Hearing ImpairedWhen you require assistance from an Aetna representative,call us during regular business hours at the number on yourID card. Our representatives can:
■ Answer benefits questions
■ Help you get referrals
■ Find care outside your area
■ Advise you on how to file complaints and appeals
■ Connect you to behavioral health services (if included inyour plan)
■ Find specific health information
■ Provide information on our Quality Management program,which evaluates the ongoing quality of our services
Multilingual hotline — 1-888-982-3862 (140 languages areavailable. You must ask for an interpreter.)
TDD 1-800-628-3323 (hearing impaired only)
Quality Management ProgramsWe have a comprehensive quality measurement andimprovement strategy, and do not view it as an isolated,departmental function. Rather, we integrate qualitymanagement and metrics into all that we do. For details onour program, goals and our progress on meeting thosegoals, go to www.aetna.com/members/health_coverage/quality/quality.html. If you do not haveInternet access and would like a hard copy of theinformation referenced here, please contact Member Servicesat the toll-free number on your ID card and request a copy.
Privacy NoticeAetna considers personal information to be confidential andhas policies and procedures in place to protect it againstunlawful use and disclosure. By “personal information,” wemean information that relates to your physical or mentalhealth or condition, the provision of health care to you, orpayment for the provision of health care to you. Personalinformation does not include publicly available informationor information that is available or reported in a summarizedor aggregate fashion but does not identify you.When necessary or appropriate for your care or treatment,the operation of our health plans, or other related activities,we use personal information internally, share it with ouraffiliates, and disclose it to health care providers (doctors,dentists, pharmacies, hospitals and other caregivers), payors(health care provider organizations, employers who sponsorself-funded health plans or who share responsibility for thepayment of benefits, and others who may be financiallyresponsible for payment for the services or benefits youreceive under your plan), other insurers, third partyadministrators, vendors, consultants, government authorities,and their respective agents. These parties are required tokeep personal information confidential as provided byapplicable law. Participating network providers are alsorequired to give you access to your medical records within areasonable amount of time after you make a request.
Some of the ways in which personal information is usedinclude claims payment; utilization review and management;medical necessity reviews; coordination of care and benefits;preventive health, early detection, and disease and casemanagement; quality assessment and improvement activities;auditing and anti-fraud activities; performance measurementand outcomes assessment; health claims analysis andreporting; health services research; data and informationsystems management; compliance with legal and regulatoryrequirements; formulary management; litigation proceedings;transfer of policies or contracts to and from other insurers,HMOs and third party administrators; underwriting activities;and due diligence activities in connection with the purchaseor sale of some or all of our business. We consider theseactivities key for the operation of our health plans. To theextent permitted by law, we use and disclose personalinformation as provided above without your consent.However, we recognize that you may not want to receiveunsolicited marketing materials unrelated to your healthbenefits. We do not disclose personal information for thesemarketing purposes unless you consent. We also havepolicies addressing circumstances in which you are unable togive consent.
To request a printed copy of our Notice of Privacy Practices,which describes in greater detail our practices concerninguse and disclosure of personal information, please write to:
Aetna Legal Support Services Department151 Farmington Avenue, W121Hartford, CT 06156
You can also visit www.aetna.com and link directly to theNotice of Privacy Practices by selecting the "Privacy Notices"link at the bottom of the page.
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Non-discrimination statementAetna does not discriminate in providing access to healthcare services on the basis of race, disability, religion, sex,sexual orientation, health, ethnicity, creed, age or nationalorigin. We are required to comply with Title VI of the CivilRights Act of 1964, the Age Discrimination Act of 1975, theAmericans with Disabilities Act, other laws applicable torecipients of federal funds, and all other applicable laws andrules.
Use of Race, Ethnicity and Language DataAetna members have the option to provide us with race/ethnicity and preferred language information. Thisinformation is voluntary and confidential. We collect thisinformation to identify, research, develop, implement and/orenhance initiatives to improve health care access, deliveryand outcomes for diverse members, and otherwise improveservices to our members. We will maintain administrative,technical and physical safeguards to protect informationconcerning member race, ethnicity and language preferencefrom inappropriate access, use or disclosure. This data will becollected, used or disclosed only in accordance with Aetnapolicies and applicable state and federal requirements. It isnot used to determine eligibility, rating or claim payment.
For more information, please visit www.aetna.com. If youdo not have Internet access and would like a hard copy ofthe information referenced here, please contact MemberServices at the toll-free number on your ID card and requesta copy.
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Special Enrollment Rights If you are declining enrollment for yourself or yourdependents (including your spouse) because of other healthinsurance or group health plan coverage, you may be able toenroll yourself and your dependents in this plan if you oryour dependents lose eligibility for that other coverage (or ifthe employer stops contributing to your or your dependents’other coverage). However, you must request enrollmentwithin 31 days after your or your dependents’ othercoverage ends (or after the employer stops contributing tothe other coverage).
In addition, if you have a new dependent as a result ofmarriage, birth, adoption or placement for adoption, youmay be able to enroll yourself and your dependents.However, you must request enrollment within 31 days aftermarriage, birth, adoption or placement for adoption. Torequest special enrollment or obtain more information,contact your benefits administrator.
Request for Certificate of Creditable CoverageIf you are a member of an insured plan sponsor or a memberof a self-insured plan sponsor who have contracted with usto provide Certificates of Prior Health Coverage, you havethe option to request a certificate.
This applies to you if you are a terminated member, or are amember who is currently active but would like a certificate toverify your status. As a terminated member, you can request acertificate for up to 24 months following the date of yourtermination. As an active member, you can request acertificate at any time. To request a Certificate of Prior HealthCoverage, please contact Member Services at the telephonenumber listed on your ID card.
Notice Regarding Women's Health and CancerRights ActUnder this health plan, coverage will be provided to a personwho is receiving benefits for a medically necessarymastectomy and who elects breast reconstruction after themastectomy for:
(1) reconstruction of the breast on which a mastectomy hasbeen performed;
(2) surgery and reconstruction of the other breast to producea symmetrical appearance;
(3) prostheses; and
(4) treatment of physical complications of all stages ofmastectomy, including lymphedemas.
This coverage will be provided in consultation with theattending physician and the patient, and will be subject tothe same annual deductibles and coinsurance provisions thatapply for the mastectomy.
If you have any questions about our coverage ofmastectomies and reconstructive surgery, please contact theMember Services number on your ID card.
Health Insurance Portability andAccountability Act The following information is provided to inform you of certain provisions contained in the Group HealthPlan, and related procedures that may be utilized by you in accordance with Federal law.
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If you need this material translated into another language, please call Member Services at 1-877-STATENJ (782-8365).
Si usted necesita este documento en otro idioma, por favor llame a Servicios al Miembro al 1-877-STATENJ (782-8365).Administered by Aetna Life Insurance Company. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage.Plan features and availability may vary by location and are subject to change. Health information programs provide general health information and are not a substitute for diagnosis or treatment bya physician or other health care professional. Discount programs provide access to discounted prices and are NOT insured benefits. The Aetna Personal Health Record ("PHR") should not be usedas the sole source of information about the member's medical history. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetnadoes not provide care or guarantee access to health services. If you are in a plan that requires the selection of a primary care physician and your primary care physician is part of an integrated deliverysystem or physician group, your primary care physician will generally refer you to specialists and hospitals that are affiliated with the delivery system or physician group. Information is believed to beaccurate as of the production date; however, it is subject to change.
The NCQA Accreditation Seal is a recognized symbol of quality. The seal, located on the front cover of your Physician Directory, signifies that your plan has earned this accreditation for service andclinical quality that meets or exceeds the NCQA's rigorous requirements for consumer protection and quality improvement. The number of stars on the seal represents the accreditation level theplan has achieved. Health care providers who have been duly recognized by the NCQA Recognition Programs are annotated in the Physician Directory.
Providers, in all settings, achieve recognition by submitting data that demonstrates they are providing quality care. The program constantly assesses key measures that were carefully defined andtested for their relationship to improved care, therefore, NCQA provider recognition is subject to change. For up-to-date information, please visit our DocFind® directory at www.aetna.com or, ifapplicable, visit the NCQA's new top-level recognition listing at www.ncqa.org/tabid/58/Default.aspx. If you do not have Internet access and would like a printed physician directory, please contactMember Services at the toll-free number shown on your Aetna ID card.
CCG 09-0272 (7/09) Available in Spanish. Disponible en Español. ©2009 Aetna Inc.
