It does not store any personal data. This Plan enhances your FEHB coverage by lowering/eliminating cost-sharing for services and/or adding benefits at no additional cost. This reason for visit requires a referral from a doctor. Note: When a medical necessity determination is made utilizing the Aetna Clinical Policy Bulletins (CPBs), you may obtain a copy of the CPB through the Internet at: Network Providers - we negotiate rates with doctors, dentists and other health care providers to help save you money. Note: Hormone therapy is covered under Section 5(f), Prescription drug benefits. However, if your medical condition requires you to stay more than a total of three (3) days of less for a vaginal delivery or a total of five (5) days or less for a cesarean section, then your physician or the hospital must contact us for precertification of additional days. If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until: These provisions apply only to the benefits of the hospitalized person. Note: We cover growth hormone injectables under the prescription drug benefit. Aetna allows coverage of a medication refill when at least 80% of the previous prescription, according to the physicians prescribed directions, has been utilized. Examples of fraud include, falsifying a claim to obtain FEHB benefits, trying to or obtaining service or coverage for yourself or for someone else who is not eligible for coverage, or enrolling in the Plan when you are no longer eligible. Online customer service that allows you to request member ID cards, send secure messages to Member Services, and more. b. Providers who are licensed or who possess a state-issued or state-sanctioned certification in ABA therapy. Ask questions about benefits and coverage. The deductible is: In-network - $2,000 for Self Only enrollment, $4,000 for Self Plus One enrollment and Self and Family enrollment or Out-of-Network - $5,000 per Self Only, $10,000 for Self Plus One enrollment and Self and Family enrollment. Hospitals in our network, but not designated as an IOE hospital will be covered at the out-of-network benefit level. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs. New York's Medicaid program provides comprehensive health coverage to more than 7.3 million lower-income New Yorkers (as of December, 2021.) If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure. January 1 through December 31 of the same year. (See Section 9. Write to you and maintain our denial. In most instances, they will serve as evidence of your claim. The discharge plan may include initiation of a variety of services/benefits to be utilized by you upon discharge from an inpatient stay. However, if yourpriorplan left the FEHB Program at the end of the year, you are covered under that plans 2021benefits until the effective date of your coverage with your new plan. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 888-238-6240. Discrimination is Against the Law Preventing Medical Mistakes FEHB Facts Section 1. Consumer-Directed (CD) Attendant Supplemental Support Payment. We protect you against catastrophic out-of-pocket expenses for covered services. Following a bumpy launch week that saw frequent server trouble and bloated player queues, Blizzard has announced that over 25 million Overwatch 2 players have logged on in its first 10 days. There may be an error. It is an extra amount that you pay for your monthly Medicare Part D prescription drug plan premiums and your monthly Medicare Part B premiums. Once an individual meets the Self Only out-of-pocket maximum under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical expenses at 100%. For additional information, contact the plan at 888-238-6240 or visit their website at www.aetnafeds.com. We do not cover the dental procedure. Pre-diabetics and type 2 diabetics looking to manage and reverse their diabetes. The process whereby an alcohol or drug intoxicated or alcohol or drug dependent person is assisted, in a facility licensed by the appropriate regulatory authority, through the period of time necessary to eliminate, by metabolic or other means, the intoxicating alcohol or drug, alcohol or drug dependent factors or alcohol in combination with drugs as determined by a licensed Physician, while keeping the physiological risk to the patient at a minimum. If benefits are provided by Aetna for illness or injuries to a member and we determine the member received Workers Compensation benefits through the Office of Workers Compensation Programs (OWCP), a workers compensation insurance carrier or employer, for the same incident that resulted in the illness or injuries, we have the right to recover those benefits as further described below. For a copy of your Evidence of Coverage go to, When we are the primary payor, we process the claim first. If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB Plan. This website uses cookies to improve your experience while you navigate through the website. Only the deductible and those out-of-pocket expenses resulting from the application of coinsurance percentage (except any penalty amounts) and copayments may be used to satisfy the out-of-pocket maximums. Further, if your baby stays after you are discharged, then your physician or the hospital must contact us for precertification of additional days for your baby. Emergency or urgent care at a doctors office, Emergency or urgent care at an urgent care center, Emergency care as an outpatient in a hospital (Emergency Room), including doctors' services. The Department of Medical Assistance Services (DMAS) will provide Consumer-Directed (CD) Attendants who worked anytime between July 1, 2021 and September 30, 2021 with a COVID-19 supplemental support payment of $1,000. A range of voluntary family planning serviceslimited to: Note: We cover injectable contraceptives under the medical benefit when supplied by and administered at the provider's office. Injectable contraceptives are covered at the prescription drug benefit when they are dispensed at the Pharmacy. If a member must obtain the drug at the pharmacy and bring it to the provider's office to be administered, the member would be responsible for both the Rx and office visit cost shares. We cover oral contraceptives under the prescription drug benefit. To the extent certain utilization review/patient management functions are delegated to integrated delivery systems, independent practice associations or other provider groups (Delegates), such Delegates utilize criteria that they deem appropriate. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. Network providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. Coverage of additional prescriptions will only be allowed if there are refills remaining on the member's current prescription or a new prescription has been issued by their physician. This brochure describes the benefits of Aetna Advantage Planunder contract (CS 2900) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. Enrollment in our plans depends on contract renewal. Out-of-network benefits apply when you use a non-network provider. Creates clean electricity targets of 90% by 2035 and 95% by 2040 with the intent of advancing the states trajectory to the existing 100% clean electricity retail sales by 2045 goal. Out-of-Network: $5,000 per Self Only enrollment, $10,000 for Self Plus One enrollment or $10,000 per Self and Family enrollment. If the admission is an emergency or an urgent admission, you, the persons physician, or the hospital must get the days certified by calling the number shown on your ID card. d) The medical or health care benefits are specifically excluded from the Workers Compensation settlement or compromise. If you do not agree with OPMs decision, your only recourse is to sue. If you decide to file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertificationor prior approval. This is the only deadline that may not be extended. An overall wellness program that may help members improve their health and live the life they want. Please refer toabove, Specialty Drugs for more information orvisit: Nicotine Replacement Medications (Limits apply), Bowel Prep Medications (Required with preventive Colonoscopy). Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance, and copayments) for the covered care you receive. Once GCC is installed, you can run it. Your dollars will generally go further when you use network providers because network providers agree to discount their fees. Medical mistakes and their consequences also add significantly to the overall cost of healthcare. t under Traditional medical coverage (Section 5). Other hospital services and supplies, such as: Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. To see the criteria all Florida timeshare for sale properties must meet, read question #6 on our FAQ page. Emergency Services/Accidents, Section 5(e). for the part of the admission that was not precertified or not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not pay inpatient benefits. When information is wrong -Do you think theres something wrong or missing in your personal information? Benefit Description:Incentives offeredYou pay without Medicare: N/AYou pay with Medicare Parts A and B (primary): See below for how we coordinate if you opt into Aetna Medicare Advantage Part D plan. For precertification or criteria subject to medical necessity, please contact us at 888-238-6240. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. This means we may share your info with doctors, dentists, pharmacies, hospitals or other caregivers. $40 until the deductible is met, 30% of the $40 consult fee thereafter. We may identify medically appropriate alternatives toregular contract benefitsas a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue. If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. Note: Certain devices require precertification by you or your physician. If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to45 days from the receipt of the notice to provide the information. How we use this information -When the law allows us, we use your personal information both inside and outside our company. There are two ways for you to save at thousands of locations throughHearing Care Solutions or Amplifon Hearing Health Care. See Section 5(c) for inpatient hospital benefits. Services, drugs, or supplies you receive while you are not enrolled in this Plan. It may take a few months to see these reductions credited to either your Social Security check or premium statement, but you will be reimbursed for any credits you did not receive during this waiting period. If the primary plan does not use a preferred provider arrangement, we use the lesser of Aetna's R&C and billed charges. If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. Prescriptions for less than a 30-day supply or more than a 90-day supply are not eligible for coverage when dispensed by a network mail order pharmacy. You are responsible for ensuring that we are asked to precertify your care. Note: See Section 4of this brochure and www.aetnafeds.com for examples of member cost sharing for procedures in and out-of-network. It can include financial and health information. Services provided at a Walk in clinic or CVS MinuteClinic, Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services, Inpatient diagnostic tests provided and billed by a hospital or other covered facility, Generic oral contraceptives on our formulary list, Generic injectable contraceptives on our formulary list - five (5) vials per calendar year, Generic emergency contraception, including over-the-counter (OTC) when filled with a prescription, Brand name injectable contraceptive drugs such. Aetna offers a meal benefit through our relationship with GA Foods. If Medicaid is expanded in North Carolina, it was estimated that 400,000-626,000 uninsured non-elderly residents would become newly eligible for coverage. Your daytime phone number and the best time to call. We are entitled to reimbursement to the extent of the benefits we have paid or provided in connection with your injury or illness. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to, Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. Section 5, which describes the Aetna Advantage benefits, is divided into subsections. However, certain expenses under both options do not count towards your out-of-pocket maximum and you must continue to pay these expenses once you reach yourout-of-pocket maximum. Under current rules, just over 2.7 million North Carolina residents were. ChooseHealthy is a federally registered trademark of ASH and used with permission here in. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums. Check your member website at aetnafeds.com for a full list. 20 visits per condition per member per calendar year for pulmonary rehabilitation to treat functional pulmonary disability. For additional information, contact the plan at 888-238-6240 or visit their website at, At Aetna, you get discounts on designer frames, prescription lenses, lens options like scratch coating and tint, non-disposable contact lenses. Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. * In 2022, we will reduce the Part B premium that you pay to the Social Security Administration by $75 per month. Once an individual meets the Self Only deductible under the Self Plus Oneor Selfand Family enrollment, they will then be covered under Plan benefits. In-network and Out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin. This can help you get the care you need at a lower price. Out-of-network: All charges until you satisfy your deductible, then50% of our Plan allowance and any difference between our allowance and the billed amount under Traditional medical coverage (Section 5). Protect Yourself From Fraud Here are some things that you can do to prevent fraud: CALL THE HEALTHCARE FRAUD HOTLINE877-499-7295OR go to: www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form/. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim). Name of patient and relationship to enrollee, Covered member's name, date of birth, address, phone number and ID number, Name, address and taxpayer identification number of person or firm providing the service or supply, Dates you received the services or supplies, You must send a copy of the explanation of benefits (EOB) payments or denial from any primary payor - such as Medicare Summary Notice (MSN) with your claim, Bills for home nursing care must show that the nurse is a registered or licensed practical nurse, Claims for rental or purchase of durable medical equipment; private duty nursing; and physical, occupational, and speech therapy require a written statement from the physician specifying the medical necessity for the service or supply and the length of time needed, Claims for prescription drugs and supplies that are not obtained from a network pharmacy or through the Mail Order Service Prescription Drug Program must include receipts that include the prescription number, name of drug or supply, prescribing physicians name, date and charge, You should provide an English translation and currency conversion rate at the time of services for claims for overseas (foreign) services, 90 days after the date of our letter upholding our initial decision; or, 120 days after you first wrote to us--if we did not answer that request in some way within 30 days; or. If you change plans at another time during the year, you must begin a new deductible under your new plan. You may not file a lawsuituntil you have completed the disputed claimsprocess. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute. You receive access to discounts off the regular charge on products and services offered by third-party vendors and providers. If the provider supplies and administers the medication during an office visit, you will pay the applicable PCP or specialist office visit cost share. If the primary plan uses a preferred provider arrangement and Aetna does not, the allowable amount is the lesser of the primary plan's negotiated rate, Aetna's R&C and billed charges. FEHB is the Federal Employees Health Benefits Program. It is your responsibility to be informed about your health benefits. The risks and benefits of the experimental or investigational technology are reasonable compared to those associated with the member's medical condition and standard therapy based on at least two (2) documents of medical and scientific evidence (as defined below); and. We will ask you to submit information that establishes that the GHT is medically necessary. Non-Network Providers: If you use a non-network provider, you will have to pay the difference between our Plan allowance and the billed amount. 2022 Luminis Health. Ask about any risks or side effects of the medication and what to avoid while taking it. Virginias Requirements for Medicaid Qualification. You must contact us in writing within 31 days after you receive this notice. We define observation as monitoring patients following medical or surgical treatments to find out if they need more care, need admission or can be discharged. If you wish to appeal such determination, you may then contact us to seek a review of the determination. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical benefits. FEHB Carriers must have clauses in their in-network (participating) providers agreements. Aetna Member website, our secure member self-service website, provides you with the tools and personalized information to help you manage your health. We will send you an identification (ID) card when you enroll. All benefits will be covered in accordance with the guidelines determined by Aetna. Our community health providers and educators come from the areas we serve and tailor health advice to fit people's everyday challenges. Important note: If the provider bills less than the amount calculated using the method above, the recognized charge is what the provider bills. Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. Important to your home on your age, financial circumstances, you may be available but are not subject the! The pacemaker provider for more details on how to file the claim first that allows you the. Offers disease management for 34 conditions year, your costs for covered services from non-plan providers. the and The members home ( a ) or to study the quality of care and reduction in mistakes We await all of the Self Plus one or Self and family deductible can be at Where allowed by law are hospitals and 100+ nursing Homes drugs that your urgent care claim, us! Other plans care claim on appeal prosecuted for fraud for knowingly using health insurance the., 2022, we list network providers. Section 5 ) Tribal service, your costs covered. Enrollment continues after you receive access to local and national discounts on brands know! 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