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For additional information, contact the plan at 888-238-6240 or visit their website at www.aetnafeds.com. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. Some of the required information is listed below. If you have not met this expense level in full, yourpriorplan will first apply your covered out-of-pocket expenses until the prior years catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. It also may exclude any backdated adjustments made by CMS. Section 9 has additional information on costs related to clinical trials. Out-of-network: Your annual out-of-pocket maximum is$20,000. See the Plan allowance definition in Section 10 for more details on how we pay out-of-network claims. Box 550, Blue Bell, PA 19422-0550. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. Retail Pharmacy, for up to a 30-day supply per prescription or refill: Mail Orderor CVSPharmacy, for a 31-day up to a 90 day supply per prescription or refill: Specialty medications must be filled through a networkspecialty pharmacy. For that, go to Section 5 Benefits. For precertification or criteria subject to medical necessity, please contact us at 888-238-6240. In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin. If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist and any in-network benefits continue until the end of your postpartum care, even if it is beyond the 90 days. If you have already met yourpriorplans catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. Check out this list of 120 best nbc news: breaking & us news alternatives. Your child age 26 or over (unlessthey aredisabled and incapable of self-support prior to age 26). Aetna is solely responsible for the selection of network providers in your area. We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods. 1) Have Medicare solely based on end stage renal disease (ESRD) and.. 2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and 3) Have Temporary Continuation of Coverage(TCC) and 1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee, 2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant. OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. Note: Non-network physicians generally will make these arrangements too, but you are responsible for any precertification requirements. We use the Planallowance/Recognized charge when calculating a members coinsurance amount. Certain drugs require your doctor to get precertification from the Plan before they can be covered under the Plan. Services include: Skilled behavioral health services provided in the home, but only when all of the following criteria are met: We cover medically necessary Applied BehaviorAnalysis (ABA) therapy when provided by network behavioral health providers. If the primary plan does not use a preferred provider arrangement, we use the lesser of Aetna's R&C and billed charges. 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. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies). (503) 714-9467. Your facility will file on the UB-04 form. To enroll in the program, call toll-free 1-800-272-3531. Is Gender Dysphor. Non-myeloablative allogeneic, reduced intensity conditioning or RIC for: Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), Aggressive non-Hodgkin lymphomas (Mantle Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms), Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL), A. Write to you and maintain our denial. The law says we must do this in a timely way. You must satisfy the deductible before your Traditional medical coverage may begin. Blood products include any product created from a component of blood such as, but not limited to, plasma, packed red blood cells, platelets, albumin, Factor VIII, Immunoglobulin, and prolastin, Dressings, splints, casts, and sterile tray services, Medical supplies and equipment, including oxygen, Anesthetics, including nurse anesthetist services. for more information on the individual requirement for MEC. However, for urgent care claims, a health care professional with knowledge of your medical condition may act as your authorized representative without your express consent. Contact your human resources office or retirement system for additional information. TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. For a complete explanation on how the Plan is authorized tooperate when others are responsible for your injuriesplease go to: www.aetnafeds.com. Hospital observation cost share is determined as anything greater than 23 hours, and Aetnas policy is to allow up to 48 hours of hospital observation without preauthorization. c) Ask you or your provider for more information. 2. (See Section 9. If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us. For urgent care claims, a health care professional with knowledge of your medical condition will be permitted to act as your authorized representative without your express consent. For the purposes of this section, we are also referring to your authorized representative when we refer to you. If no one contacts us, we will decide whether the hospital stay was medically necessary. The member is not responsible for amounts that are billed by network providers that are greater than our Plan allowance. Information on the FEHB Program and plans available to you, A list of agencies that participate in Employee Express, Information on and links to other electronic enrollment systems, What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire, When the next Open Season for enrollment begins, If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage. To obtain claim forms or other claims filing advice or answers about your benefits, contact us at 888-238-6240. Make Offer. Save on accessories like eyeglass chains, lens cases, cleaners, and nonprescription sunglasses. An approved clinical trial includes a phase I, phase II, phase III or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application. To transport a member from hospital to home, skilled nursing facility or nursing home when the member cannot be safely or adequately transported in another way without endangering the individuals health, whether or not such other transportation is actually available; or. Necessary cookies are absolutely essential for the website to function properly. Aetna Medicare Advantage Plan (PPO with ESA) is a Medicare contract separate from the FEHB Aetna Advantage Plan and depends on contract renewal with CMS. See Section 5(c) for inpatient hospital benefits. Bluegreen timeshare We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. Choose a doctor with whom you feel comfortable talking. Yes, its on the social security website. Children with or eligible for employer-provided health insurance Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday. In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin. Regarding this point, the following article can be referred to for more information. You do not need to precertify your vaginal delivery; see below for other circumstances, such as extended stays for you or your baby. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits. The most current information on our Network providers is also on our website at, Inpatient confinements (except hospice) - For example, surgical and nonsurgical stays; stays in a skilled nursing facility or rehabilitation facility; and maternity and newborn stays that exceed the standard length of stay (LOS), Ambulance - Precertification required for transportation by fixed-wing aircraft (plane). By choosing this plan, retired enrollees age 65 and over with Medicare as primary coverage, agree that you have or will have Medicare Parts A and B by your effective date. View current visitation policies for our hospitals. We do not cover these costs. Your Cost for Covered Services Section 5. Please remember that we do not make decisions about plan eligibility issues. To be eligible for Medicaid in Virginia, you have to belong to one of the designated patient groups. The Centers for Medicare & Medicaid Services (CMS) announced this change in policy in January 2020. Note: Some tests provided during a routine physical may not be considered preventive. Blue Cross Blue Shield is not the only health insurance company that does not cover bioidentical hormone therapy or bioidentical hormone pellets. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate,in the same option of the same plan; or. B. Your annual deductible is$2,000 for a Self Only enrollment,$4,000 for a Self Plus One enrollmentand$4,000 for Self and Family enrollment in-network and$5,000 for a Self Only enrollment, $10,000 for a Self Plus One,and$10,000 for a Self and Family enrollment out-of-network. How You Get Care Section 4. Please see www.aetnafeds.com for information on Teladoc service. Here is how we figure out the Plan allowance/recognized charge. When you use our network providers, you will receive covered services at reduced costs. Note: We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. Benefits described in this brochure are available to all members meeting medical necessity guidelines. Savings options on hearing aids and exams. Our decision to offeror withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8). We cover professional services by licensed professional mental health and substance use disorder treatmentpractitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists. In-network and Out-of-network out-of-pocket maximums do not cross apply and will need to be met separately in order for eligible medical expenses to be paid at 100%. The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. 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%. We may delay processing or deny benefits for your claim if you do not respond. Our deadline for responding to your claim is stayed while we await all of the additional information needed to process your claim. If the provider does not resolve the matter, call us at 888-238-6240 and explain the situation. It also allows Aetna to coordinate your transition from the inpatient setting to the next level of care (discharge planning), or to register you for specialized programs like disease management, case management, or our prenatal program. We calculate a members coinsurance using these negotiated rates. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. (See Section 5. No verbal statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. Claims process when you have the Original Medicare Plan You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan. Note: Teladoc is not available for phone service in Idaho (video consults only). Contact your human resources office or retirement system for additional information. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment. Aetna makes no payment to the third parties; you are responsible for the full cost. A comprehensive range of services, such as: Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. 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. An overall wellness program that may help members improve their health and live the life they want. ), Note: We will only cover GHT when we preauthorize the treatment. Medicare Advantage (Part C) for additional details.). You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays health care expenses without regard to fault. What personal information is and what it isnt By "personal information," we mean that which can identify you. The underbanked represented 14% of U.S. households, or 18. Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under Organ/Tissue Transplants Section 5(b). RSS Feed. You are a family member no longer eligible for coverage. Save copies of all medical bills, including those you accumulate to satisfy your deductible. Your Network primary care physician or specialist will make necessary hospital arrangements and supervise your care. Medicaid pays for a wide-range of services, depending on your age, financial circumstances, family situation, or living arrangements. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child. Note: Over-the-counter and appropriateprescription drugs approved by the FDA to treat nicotinedependence are covered under the Tobaccocessationprogram. 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. Its one way for the CMS to address the opioid crisis, which has been linked to doctors overprescribing opioids to patients in pain. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. Medical mistakes and their consequences also add significantly to the overall cost of healthcare. Hearing products and services are provided by Hearing Care Solutions and Amplifon Hearing Health Care.

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