Haris Ashley
Aetna is a health insurance company that provides a range of insurance plans and services to meet the unique needs of individuals and families. These include Medicare, Medicaid, dental, vision, and prescription drug coverage, as well as international coverage for those living or working abroad. Aetna also offers fitness classes and at-home workout kits for members who want to improve their physical health. In addition, Aetna provides access to a 24-hour nurse line and confidential medical information services. Aetna's Clinical Policy Bulletins (CPBs) define the company's clinical policy, and medical necessity determinations are made on a case-by-case basis, with members having the right to appeal coverage decisions.
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What You'll Learn
Aetna's Clinical Policy Bulletins (CPBs)
Aetna Clinical Policy Bulletins (CPBs) are designed to assist in administering plan benefits and do not constitute medical advice. They can be highly technical and are meant to be used by professional staff to make clinical determinations in connection with coverage decisions. The CPBs express Aetna's determination of whether certain services or supplies are medically necessary, experimental, investigational, unproven, or cosmetic. They do not constitute a description of plan benefits.
The five-character codes included in the CPBs are obtained from Current Procedural Terminology (CPT), which is a listing of descriptive terms and five-character identifying codes and modifiers for reporting medical services and procedures performed by physicians. CPT is copyrighted by the American Medical Association (AMA), but the content of the CPBs is the responsibility of Aetna and does not imply endorsement by the AMA.
The discussion, analysis, conclusions, and positions reflected in the CPBs, including any reference to a specific provider, product, process, or service by name, trademark, or manufacturer, constitute Aetna's opinion and are made without any intent to defame. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. In the event that a member disagrees with a coverage determination, they have the right to appeal the decision and may have the opportunity for an independent external review.
It is important for members to review the CPBs with their providers to fully understand Aetna's policies.
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SBC and uniform glossary
The Summary of Benefits and Coverage (SBC) is a document that outlines an individual's health plan and benefits. It includes information on which doctors, hospitals, and providers are in your network, as well as drug coverage. The SBC is provided at important points in the enrollment process, such as when applying for or renewing coverage. It is also available in non-English languages.
The SBC must adhere to specific standards regarding appearance, language, and form. It must be presented in a uniform format, be no longer than four double-sided pages, and use a minimum of 12-point font. The language used in the SBC must be understandable to the average plan enrollee and culturally appropriate for the intended audience.
The uniform glossary is a document that explains the terms used in the SBC. It is available upon request and must be provided in the form issued by the HHS. This glossary includes general terms used on the Aetna website and in health insurance plans.
The glossary covers a range of topics, including:
- Accidental death and dismemberment/personal loss (AD&PL) or AD&D Ultra®: This benefit can be paid to the insured person after an accidental injury or to a beneficiary after the insured person's death. It covers losses from accidental death and dismemberment and other unexpected events, such as loss of sight, speech, or hearing.
- Advanced directives: A written document designating someone to make healthcare decisions on your behalf when you are unable to communicate your wishes.
- Do not hospitalize: Allows individuals to decide they do not want to be hospitalized and would prefer to receive care in their current location.
- Do not intubate: Indicates that an individual does not wish to have a breathing tube or machine to breathe for them.
- Do Not Resuscitate/DNR: Specifies that an individual does not want cardiopulmonary resuscitation (CPR) or other treatments to restart their heart and breathing if they stop.
- Grief: The emotional response to a significant loss, often characterized by sadness and pain.
- Hospice facility: A setting for patient-directed care that provides medical, spiritual, and emotional support for individuals at or near the end of life.
These documents are designed to help individuals understand their health plan options, make informed decisions about their care, and navigate their chosen health plan effectively.
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Precertification
Aetna, as a brand name, is used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates. Health benefits and health insurance plans offered by Aetna contain exclusions and limitations. Precertification applies to various Aetna plans, including Aetna Choice® POS, Aetna Choice POS II, and Aetna Medicare℠ Plan (PPO), to name a few.
To check if a service requires precertification, you can refer to the precertification lists available on the Aetna website or utilize the CPT code lookup tool. Additionally, you can call the precertification number on the member's ID card. It is important to note that Aetna asks providers not to use the EDI process for requesting precertification.
Physicians can 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 Aetna's Clinical Policy Bulletin. Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, but medical necessity determinations are made on a case-by-case basis. Members have the right to appeal coverage determinations and request an independent external review under certain circumstances.
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Medicare plan
Aetna Medicare is an HMO, PPO plan with a Medicare contract. It offers a range of Medicare Advantage plans that include prescription drug coverage, dental, vision, hearing, and other benefits.
Aetna's Medicare Advantage plans are designed to provide comprehensive health coverage and include additional benefits such as dental, vision, hearing, and prescription drug coverage. These plans are tailored to meet individual needs and are available in all 50 states and Washington, D.C.
The Medicare Advantage health maintenance organization (HMO) plans allow members to choose a primary care provider within a network of Aetna Medicare HMO providers and hospitals. This ensures coordinated care and helps members get the right treatment at the right time.
The Medicare Advantage preferred provider organization (PPO) plans offer more flexibility, allowing members to visit Medicare-approved providers, both in and out of the provider network, who accept Aetna plan terms. This gives members the freedom to choose their healthcare providers.
Aetna also offers Medicare Advantage targeted SNP plans for individuals with specific needs, such as those with chronic health conditions or those who are dual eligible for Medicaid. These plans are designed to provide customized care that fits the unique requirements of each member.
In addition to the above, Aetna Medicare provides access to SilverSneakers instructor-led group fitness classes and the Resources For Living program, which helps members find community services and resources.
To determine your specific Aetna Medicare plan, you can review the plan benefit information provided to you. You can also refer to your Aetna member ID card, which will indicate your plan name and details.
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Aetna Dental
Aetna offers dental insurance plans for individuals and families, including the Aetna Dental® Direct plan, which provides coverage for dental check-ups, cleanings, and X-rays, as well as fillings, crowns, and root canals. Plan options start at $20, and members can also add vision coverage. Aetna Dental plans come with special perks and discounts, including exclusive offers from CVS Health® and no limits on savings.
Aetna offers group dental insurance plans for employers, providing significant discounts for members and virtual and mobile care options. Employers can choose from four affordable dental plans, including virtual dentist visits, at-home orthodontics, and mobile dentistry services at the workplace.
Aetna also offers Dental DMO (Dental Maintenance Organization) and PPO (Preferred Provider Organization) plans. In Illinois, the Aetna Dental DMO plan provides limited out-of-network benefits, while in Virginia, the DMO plan is known as the Aetna Dental Network Only (DNO) plan. The Aetna Dental PPO plan, on the other hand, allows members to access virtual dentistry options for routine evaluations, second opinions, referrals, and prescriptions.
The Aetna Dental PPO service area in Massachusetts includes Barnstable, Berkshire, Bristol, Essex, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk, and Worcester Counties. Members residing outside of this service area seeking in-network care would need to seek services within the approved area.
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Frequently asked questions
You can access this information by logging into the Aetna member website, downloading the Aetna Health app, or calling the Member Services team.
Each main plan type has more than one subtype. Some subtypes have five tiers of coverage, while others have four, three, or two tiers.
You can check your Summary of Benefits and Coverage (SBC), which includes the name of your health plan and information about which doctors, hospitals, and providers are in your network. You can also look up drug coverage on the Aetna website without logging in.
You can look up drug coverage on the Aetna website or by using the Aetna Health app. You will need to know your pharmacy plan name, which you can find on your SBC.
