Jeffrey Wade
Aetna is the brand name used for products and services provided by the Aetna group of companies, including Aetna Life Insurance Company and its affiliates. Aetna complies with all applicable Federal civil rights laws, including Title VII of the Civil Rights Act of 1964. The company offers health benefits and health insurance plans, including the Federal Employees Health Benefits (FEHB) Program, which provides health coverage to federal employees in all 50 states and the District of Columbia.
| Characteristics | Values |
|---|---|
| Name | Aetna |
| Company | Aetna Life Insurance Company |
| Service Area | All 50 states and the District of Columbia |
| Website | www.aetnafeds.com |
| Contact Number | 888-238-6240 |
| Address | Aetna, Federal Plans, PO Box 550, Blue Bell, PA 19422-0550 |
| Compliance | Complies with all applicable Federal civil rights laws, including Title VII of the Civil Rights Act of 1964 |
| Clinical Policy | Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case-by-case basis |
| Member Rights | Members have the right to appeal coverage decisions and request an independent external review of coverage denials |
| PHI Sharing | PHI may be shared with doctors, dentists, pharmacies, hospitals, insurers, vendors, government offices, and third-party administrators. All parties are legally required to maintain privacy. |
| Pharmacy Drug Coverage | Formulary drugs are subject to change, and members pay a lower prescription copayment for generic formulary drugs |
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What You'll Learn
- Aetna is the brand name for products and services provided by Aetna Life Insurance Company and affiliates
- Aetna complies with Federal civil rights laws, including the Civil Rights Act of 1964
- Clinical Policy Bulletins define Aetna's clinical policy, but coverage decisions are made on a case-by-case basis
- Aetna members can appeal coverage decisions and request independent external reviews of denials
- Aetna's Federal Employees Health Benefits (FEHB) Program may share member PHI with caregivers and other entities
Aetna is the brand name for products and services provided by Aetna Life Insurance Company and affiliates
Aetna is a well-known name in the health insurance industry, offering a range of products and services to its customers. The name "Aetna" is used as a brand name by the group of companies that provide these products and services, including Aetna Life Insurance Company and its affiliates.
Aetna has a long history dating back to its roots in the insurance industry, specifically fire insurance. Over time, it expanded its offerings to include various types of insurance, such as windstorm, tornado, leasehold, and ocean and inland marine insurance. The company also ventured into the life insurance business, forming a Group department to sell group life insurance policies. With its diverse range of insurance products, Aetna established itself as a prominent player in the insurance market.
One notable aspect of Aetna's business is its focus on health-related services. As an American managed healthcare company, Aetna offers traditional and consumer-directed healthcare insurance plans, as well as a range of related services. These services include medical, pharmaceutical, dental, behavioral health, long-term care, and disability plans. Aetna's healthcare services are primarily provided through employer-paid insurance and benefit programs, as well as Medicare. The company boasts an extensive network of healthcare professionals, hospitals, and medical members, ensuring wide coverage for its customers.
Aetna has also faced some challenges and controversies over the years. There have been instances where Aetna has been fined by state authorities for violations related to health insurance operations, including failure to provide policyholders with information about their rights and timely notification of decisions. Additionally, Aetna has been involved in lawsuits, such as the class-action lawsuit brought by physicians and medical societies, which resulted in a settlement agreement to improve communication and the quality of the healthcare system.
Despite these setbacks, Aetna continues to be a significant player in the healthcare and insurance industries. With its range of products and services, Aetna serves millions of customers and plays a crucial role in providing access to healthcare and financial protection for individuals and families across the United States. The company's history, evolution, and impact on the industry showcase the importance of the Aetna brand and its contributions to the field of insurance and healthcare.
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Aetna complies with Federal civil rights laws, including the Civil Rights Act of 1964
In addition, the Act has been interpreted to include protection against employment discrimination based on gender identity or transgender status. This interpretation was established in a 2012 ruling by the Equal Employment Opportunity Commission (EEOC), which stated that discrimination on the basis of gender identity qualified as discrimination on the basis of sex.
The Civil Rights Act of 1964 also established the principle that federal law overrides state law in cases of contradiction. This Act has been upheld in landmark cases such as Heart of Atlanta Motel v. United States, which established the law's constitutionality, and Lau v. Nichols, where the Supreme Court ruled in favour of accommodating non-English speaking students.
Aetna's compliance with federal civil rights laws, including the Civil Rights Act of 1964, ensures that it upholds these principles and provides equal access and opportunities to all individuals, regardless of protected characteristics.
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Clinical Policy Bulletins define Aetna's clinical policy, but coverage decisions are made on a case-by-case basis
Clinical Policy Bulletins (CPBs) outline Aetna's clinical policies and the medical, dental, and pharmaceutical services that may or may not be covered. They are based on objective, credible sources such as scientific literature, guidelines, consensus statements, and expert opinions. However, it's important to note that CPBs are not a substitute for medical or dental advice, and members should discuss the bulletins with their treating providers to understand how they apply to their specific situation.
While CPBs provide a general framework, coverage decisions are made on a case-by-case basis, taking into account the medical necessity of the services or supplies in question. This means that even if a service or treatment is mentioned in the CPBs, the coverage decision for each individual case will depend on the specific circumstances and medical necessity as determined by the treating provider.
Aetna recognizes that each member's situation is unique, and their medical necessity determinations are made accordingly. If a member disagrees with a coverage determination, they have the right to appeal the decision and may be eligible for an internal and/or independent external appeal in accordance with applicable federal or state law. This ensures that members have a voice in the process and can seek additional review if they feel their specific circumstances warrant it.
It is important to highlight that CPBs are not contracts and do not constitute legal advice. In the event of a conflict between plan documents and the information in the CPBs, the plan documents take precedence. Additionally, members should be aware that applicable state mandates and certain plan-specific considerations may supersede the general guidelines outlined in the CPBs.
While CPBs provide valuable insight into Aetna's clinical policies and coverage considerations, the specific details of a member's plan, along with individual circumstances, will ultimately determine the coverage provided. Members are encouraged to review the CPBs in conjunction with their treating providers to ensure they fully understand the benefits and limitations of their Aetna plan.
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Aetna members can appeal coverage decisions and request independent external reviews of denials
Aetna is a popular healthcare insurance company that offers a range of plans to its members. As with any insurance company, there are times when a member may disagree with a coverage determination or decision. In such cases, Aetna provides its members with the right to appeal the decision and request an internal review. This is known as the Aetna dispute and appeal process.
The first step in the appeal process is to understand the reason for the denial of coverage. Aetna's Clinical Policy Bulletins (CPBs) are highly technical documents that outline the company's clinical policies and are used by professional staff to make clinical determinations regarding coverage. Members are encouraged to review these bulletins with their healthcare providers to fully understand the policies and determine if an appeal is necessary.
If a member wishes to proceed with an appeal, they can do so by following the steps outlined on the Aetna website. The member has the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. The appeal process may vary depending on the specific plan and the reason for the denial of coverage.
In some cases, members may be eligible for an expedited appeal if their physician certifies that a delay in service would put their health, life, or recovery at serious risk or cause severe pain. This type of appeal has a shorter turnaround time, with decisions being made within 36 to 72 hours of receiving the request.
If a member has gone through the internal appeal process and is still not satisfied with the outcome, they may be able to request an independent external review. This process involves having a third-party organization, known as an Independent Review Organization (IRO), review the case. The IRO chooses a board-certified physician in the relevant medical specialty to examine the case and make a determination. The external review process generally takes place within 30 calendar days of the request.
It is important to note that the availability and specifics of the appeal and external review processes may vary depending on the member's plan and the applicable state and federal laws. Members can refer to their specific plan details and consult with their healthcare providers to understand their options and rights in the event of a coverage dispute.
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Aetna's Federal Employees Health Benefits (FEHB) Program may share member PHI with caregivers and other entities
The Aetna Advantage Plan is a Federal Employees Health Benefits (FEHB) Program. As part of this program, Aetna is required to share members' Protected Health Information (PHI) with the Office of Personnel Management (OPM) for its claims data warehouse. This data is used for the FEHB program and may be shared with doctors, dentists, pharmacies, hospitals, or other caregivers. It may also be shared with other insurers, vendors, government offices, or third-party administrators. However, by law, all these parties must keep member information private.
There are times when Aetna does need permission to disclose personal information. This is outlined in their Notice of Privacy Practices, which explains how they use and disclose PHI. Members can obtain a copy of this notice by visiting the member website or calling the toll-free number on their ID card.
The FEHB program offers a range of benefits to federal employees, including prescription drug coverage and wellness programs. For example, members can earn wellness credits for completing select wellness programs, such as routine physicals, flu shots, and biometric screenings. Additionally, the FEHB program coordinates with other coverage, such as Medicare and the Federal Employees Dental/Vision Insurance Program (FEDVIP).
The FEHB program also provides resources to prevent fraud, waste, and abuse. Members are advised to protect their personal information and not disclose their plan identification (ID) number to anyone except authorized individuals. Overall, the FEHB program offers comprehensive health coverage to federal employees, and members can rest assured that their PHI will be kept private by all parties involved.
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Frequently asked questions
Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates.
Aetna offers a Federal Employees Health Benefits Program, which is a health coverage plan that meets the minimum value standard for the benefits it provides. Enrollment in this plan is limited to those who live or work in the geographic service area.
If your enrollment continues after you are no longer eligible for coverage (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed by your provider for services received and may also be prosecuted for fraud for knowingly using health insurance benefits for which premiums have not been paid.
