Haris Ashley
Aetna is a brand name for health insurance products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates. The company offers Medicaid insurance coverage, a federally and state-funded health insurance program for people with limited assets, special needs, or disabilities. Each benefit plan defines which services are covered, excluded, or subject to dollar caps or limits. Members must consult their benefit plan to determine if there are any exclusions or limitations applicable to a service or supply. While Aetna provides telehealth services, allowing members to connect with doctors by phone, video, or app, it is unclear if these services are included in the Medicaid insurance plan.
| Characteristics | Values |
|---|---|
| Telemedicine services | Available through the Aetna HealthSM app and Teladoc Health website |
| Teladoc Health | Available with all fully insured plans; self-funded customers must opt in |
| Teladoc Health providers | Licensed |
| Teladoc Health cost | $45 or less per visit |
| Nurse line with video access | Included in all medical plans, for all groups |
| Nurse line | Toll-free number or email |
| Nurse advice | Non-diagnostic; nurses do not prescribe or give medical advice |
| Exclusions and limitations | Applicable to health benefits and health insurance plans |
| Medicaid | Offered at no or very low cost for those who qualify |
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What You'll Learn
- Telehealth services for Aetna members
- Telemedicine services for short-term illnesses
- Exclusions and limitations of health benefits and health insurance plans
- Clinical Policy Bulletins (CPBs) and their impact on coverage decisions
- The right to appeal a coverage determination and request an independent external review
Telehealth services for Aetna members
Aetna members can access telemedicine services to connect with a doctor by phone, video, or app for treatment of short-term illnesses. Members can access Teladoc Health through the Aetna HealthSM app or the Teladoc Health website to connect with a provider. Members can also call 1-855-835-2362 to speak with a licensed Teladoc Health provider.
Teladoc is included with all fully insured plans, but self-funded customers must opt in. Members can talk with a registered nurse about tests, procedures, and treatments anytime, day or night, by calling a toll-free number or emailing from their member website. The nurse line with video access is included in all medical plans for all groups, and custom options can be added. It is important to note that nurses do not diagnose, prescribe, or give medical advice.
The general medical cost for telemedicine services is $45 or less per visit. However, members should check their plan details to understand what their plan covers, as each benefit plan defines which services are covered, excluded, or subject to dollar caps or other limits. For example, adolescent mental health services (ages 13+) are limited to counseling only, while mental health medication management and psychiatry services are only available for adults 18+.
In the event that a member disagrees with a coverage determination, Aetna provides the right to appeal the decision and request an independent external review. Additionally, Clinical Policy Bulletins (CPBs) are subject to change and should be reviewed by members and their providers to understand Aetna's policies and coverage decisions, which are made on a case-by-case basis.
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Telemedicine services for short-term illnesses
Telemedicine services are available for Aetna members seeking treatment for short-term illnesses. Members can connect with doctors by phone, video, or app, 24/7, and receive care from the comfort of their homes. This is especially useful when members are unable to make in-person visits or want to avoid the ER.
Aetna members can take advantage of virtual primary care and virtual mental health services, with a range of options to fit their personal health needs. Many specialists also offer virtual care, allowing members to quickly access the care they need. To get started, members can check their plan details to understand what their plan covers and then download the Aetna HealthSM app to connect with a provider.
In addition to convenience and flexibility, telemedicine services can also help with documentation for short-term disability benefits. For example, in a short-term disability case involving an employee with flu symptoms, the employee could have benefited from using telemedicine services to obtain the necessary documentation to activate their short-term disability benefits.
It is important to note that coverage for telemedicine services may be mandated by applicable legal requirements of a State, the Federal government, or CMS for Medicare and Medicaid members. Members are advised to review Clinical Policy Bulletins (CPBs) with their providers to fully understand coverage policies. In case of disagreement with a coverage determination, Aetna provides members with the right to appeal the decision and request an independent external review under certain circumstances.
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Exclusions and limitations of health benefits and health insurance plans
Health benefits and health insurance plans contain a variety of exclusions and limitations that are important to understand. Firstly, it is crucial to note that health plans can vary by state, and certain coverage may be mandated by applicable legal requirements of a state or the federal government. For example, Aetna members' coverage may be subject to such requirements, and their Clinical Policy Bulletins (CPBs) are regularly updated, so members should review these with their providers to understand their policies.
Exclusions and limitations can vary widely depending on the insurance provider and the specific plan. Some common exclusions include pre-existing conditions, sports-related injuries, substance abuse treatment, suicide and self-inflicted injuries, and mental healthcare. For example, adolescent mental health services in some plans are limited to counseling only, and medication management and psychiatry services are only available for adults. Additionally, dental and optical care often require an optional benefit, and maternity coverage is typically not automatically included.
It is also important to understand the limitations of in-network and out-of-network care. Out-of-pocket costs are usually higher when visiting an out-of-network doctor, and some plans may only cover out-of-network care in an emergency. In such cases, the out-of-network doctor can bill the patient for any amount over the recognized or allowed charge by the insurance provider, which is known as "balance billing."
When considering exclusions and limitations, it is essential to carefully review the specific details of your health insurance plan. Understanding what your policy does not cover is just as crucial as knowing what it does cover.
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Clinical Policy Bulletins (CPBs) and their impact on coverage decisions
Clinical Policy Bulletins (CPBs) are highly technical documents that outline the clinical determinations made by Aetna's professional staff in connection with coverage decisions. They detail the medical, dental, and pharmacy services that Aetna considers medically necessary, cosmetic, or experimental and unproven. These bulletins are based on credible sources such as scientific literature, guidelines, consensus statements, and expert opinions. CPBs are regularly updated and subject to change, so members are advised to review them with their providers to fully understand the policies and any applicable legal requirements.
CPBs are designed to assist in administering plan benefits but do not constitute medical advice. Treating providers are solely responsible for medical advice and the treatment of members. While CPBs define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. In certain instances, a physician may request a peer-to-peer review if they have questions or wish to discuss a medical necessity precertification determination made by the medical director in accordance with the CPB.
The five-character codes included in the CPBs are obtained from the Current Procedural Terminology (CPT) listing of the American Medical Association (AMA). These codes are used for reporting medical services and procedures performed by physicians. CPBs also include references to standard HIPAA-compliant code sets to facilitate billing and payment for covered services. When billing, the most appropriate code as of the effective date of the submission must be used.
If a member disagrees with a coverage determination, they have the right to appeal the decision and request an independent external review based on medical necessity. CPBs are subject to change based on clinical developments and available resources, and Aetna reserves the right to revise conclusions as clinical information evolves.
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The right to appeal a coverage determination and request an independent external review
If a member disagrees with a coverage determination, they have the right to appeal the decision. In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or the experimental and investigational status of the service or supply in question. This opportunity is available when the member is financially responsible for a sum of $500 or greater. However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA plans.
The appeals process is initiated by submitting a dispute online through the Availity provider website. The process for determining whether the dispute goes to a reconsideration or an appeal is determined by Aetna using specific criteria. An appeal is a written request by a practitioner or organisational provider to change an adverse initial claim decision based on medical necessity or experimental/investigational coverage criteria. It can also be a request to change a denial for non-inpatient hospital services that were denied for not receiving prior approval, or an adverse decision on a claim where a required authorization wasn't obtained.
Aetna offers providers an opportunity to present additional information and discuss their cases with a peer-to-peer reviewer as part of the utilisation review coverage determination process. This occurs prior to an appeal and incorporates state, federal, CMS and NCQA requirements. Reconsiderations are formal reviews of claims reimbursements or coding decisions, or claims that require reprocessing. Appeals are requests to change a reconsideration decision, an initial utilisation review decision, or an initial claim decision based on medical necessity or experimental/investigational coverage criteria. The timeframe for appeals involving utilisation review issues or claims issues based on medical necessity or experimental/investigational coverage criteria is 180 calendar days.
If a member is hospitalised, they will receive a notice called "An Important Message from Medicare about Your Rights". This notice must be signed to indicate that the member understands their rights as a hospital patient. These rights include the right to receive Medicare-covered services during and after their hospital stay, the right to be involved in any decisions about their hospital stay, and the right to appeal their discharge decision if they think they are being discharged from the hospital too soon.
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Frequently asked questions
Yes, Aetna offers telehealth services, allowing members to connect with doctors by phone, video, or app. Members can also talk to a registered nurse about tests, procedures, and treatments. However, it is important to note that availability may vary based on location and plan type. Members should check their specific plan details to understand their coverage.
Members can access telehealth services through the Aetna HealthSM app or by visiting the Teladoc Health website. Additionally, they provide a toll-free number to call and connect with a licensed Teladoc Health provider.
The general medical cost for each telehealth visit is $45 or less. However, members should refer to their specific plan details to understand any potential out-of-pocket expenses or limitations.
