Example: A five-day hospital stay- comparison of member costs in network versusout-of-network (see additional examples on our website: Amount Aetna uses to calculate payment -in-network rate (Doctors, hospitals and other health care providers in Aetnas network accept Aetnas payment rate and agree that you owe only your deductible and coinsurance), Amount Aetna uses to calculate payment -Recognized amount out-of-network (When you go out of network, Aetna determines a recognized amount. Note: We cover related medical and hospital expenses of the donor when we cover the recipient. Provider networks may be more extensive in some areas than others. This Plan enhances your FEHB coverage by lowering/eliminating cost-sharing for services and/or adding benefits at no additional cost. Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies. Ask questions if you have doubts or concerns. Plus, national chains like LensCrafters, Trythese natural products andservices* at a discount. Join Our Media Lists. Medical necessity means that the service or supply is provided by a physician or other health care provider exercising prudent clinical judgment for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that provision of the service or supply is: For these purposes, generally accepted standards of medical practice, means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, or otherwise consistent with physician specialty society recommendations and the views of physicians practicing in relevant clinical areas and any other relevant factors. All surgical requests must be preauthorized. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another. The member is not responsible for amounts that are billed by network providers that are greater than our Plan allowance. Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday. Certain Specialty Formulary medications identified on the Specialty Drug Listmay be covered under the medical or pharmacy section of this brochure. Members are responsible for their coinsurance portion of our Plan allowance, as well as any expenses over that limit that the non-network provider may have billed. Aetna Advantage Plan Benefits Overview, Non-FEHB Benefits Available to Plan Members, Section 6. Providing the care you deserve in your community. These cookies help provide information on metrics the number of visitors, bounce rate, traffic source, etc. Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount. You can access network providers online by visiting our website at, OPM requires that all FEHB Plans provide certain information to their FEHB members. Members must make sure their physicians obtain prior approval/precertification for certain prescription drugs and supplies before coverage applies. You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare. This cookie is set by GDPR Cookie Consent plugin. Once enrolled in your FEHB Program Plan, you should contact your carrier directly for address updates and questions about your benefit coverage. Compare the top features, pricing, pros & cons and user ratings to suit your needs. There may be an error. In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin. To learn more about this plans accreditation(s), please visit the following website: Our Aetna Advantage Plan is a comprehensive medical plan. Professional services (including Acupuncture - when provided as anesthesia for a covered surgery)provided in: Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate. Natural children, adopted children, and stepchildren Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday. For anesthesia, our rate is 105% of the rates CMS establishes for those services or supplies. You agree that you will be enrolled in our Aetna Medicare Advantage Plan. Because you are still responsible for ensuring that we are asked to precertify your care, you should always ask your physician or hospital whether they have contacted us. You may also see an additional charge if you qualify for the Income-Related Monthly Adjustment Amount (IRMAA). Definitions of Terms We Use in This Brochure, Summary of Benefits for the Aetna Advantage Plan - 2022, 2022 Rate Information for the Aetna Advantage Plan, Except for necessary technical terms, we use common words. See FEHB Factsfor details. Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications or nutritional supplements you are taking. If the expense is not covered in full by the primary plan, we determine our allowance. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums. Aetna Medicare Advantage plan is subject to Medicare rules. The online reporting form is the desired method of reporting fraud in order to ensure accuracy. Television's destination for Your share of the premium rate will remain the same for Self Only, Self Plus One, and Self and Family. These negotiated rates are our Plan allowance for network providers. Aetna Medicare Advantage plan is subject to Medicare rules. This policy helps to protect you from preventable medical errors and improve the quality of care you receive. Your facility will file on the UB-04 form. When Original Medicare is the primary payor, Medicare processes your claim first. Electrocardiogram and electroencephalogram (EEG), Genetic Counseling and Evaluation for BRCA Testing. 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. Out-of-network: Your annual out-of-pocket maximum is$20,000. The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums. Care furnished during a period of time when your family or usual caretaker cannot, or will not, attend to your needs. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. You must satisfy your deductible before your Traditional medical coverage begins. To see the criteria all Florida timeshare for sale properties must meet, read question #6 on our FAQ page. If Medicare does not have a rate, we use one or more of the items below to determine the rate: The method CMS uses to set Medicare rates, What other providers charge or accept as payment, How much work it takes to perform a service, Other things as needed to decide what rate is reasonable for a particular service or supply. Note: Teladoc is not available for phone service in Idaho (video consults only). Members must call Member Services at 888-238-6240 for authorization. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at, You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at, Well-child care charges for routine examinations, immunizations and care (up to age 22), Seven (7) routine exams from birth to age 12 months, Three (3) routine exams from age 12 months to 24 months, Three (3) routine exams from age 24 months to 36 months, One (1) routine exam per year thereafter to age 22, Hearing loss screening of newborns provided by a participating hospital before discharge, One (1) routine eye exam every 12 months through age 17 to determine the need for vision correction, One (1) routine hearing exam every 24 months through age 17 to determine the need for hearing correction. Insertion of internal prosthetic devices. You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. How we use this information -When the law allows us, we use your personal information both inside and outside our company. For laboratory, our rate is 75% of the rates CMS establishes for those services or supplies. Oct 25, 2011. See Section 5(c) for inpatient hospital benefits. The example below is based on the following Aetna health benefits and insurance plan features and assumes youve already met your deductible: What your plan pays (plan coinsurance): 70% in-network/50% out-of-network, What you pay (coinsurance): 30% in-network/50% out-of-network, Your out-of-pocket maximum: $7,500/$15,000 in-network; $10,000/$20,000 out-of-network***, Example: A five-day hospital stay- comparison of member costs in network versusout-of-network (see additional examples on our website: www.aetnafeds.com), Hospital Bill - Amount BilledIn-network:$25,000Out-of-network:$25,000, Amount Aetna uses to calculate payment -in-network rate (Doctors, hospitals and other health care providers in Aetnas network accept Aetnas payment rate and agree that you owe only your deductible and coinsurance)In-network:$8,750Out-of-network:N/A, Amount Aetna uses to calculate payment -Recognized amount out-of-network (When you go out of network, Aetna determines a recognized amount. ACA's Medicaid eligibility expansion in North Carolina. t under Traditional medical coverage (Section 5). You will then have up to 48 hours from the receipt of this notice to providethe requiredinformation. In Gov. In today's video i am jumping into 2018 honda odyssey from the k1 speed car pack, swapping the Gran Turismo 7 GT7 PS5 Walkthrough Gameplay 1 includes a Review, Full Game Gameplay and. To find out if you need to do something to file your claim, call us at 888-238-6240. Make Offer. * **, Dialysis hemodialysis and peritoneal dialysis, Intravenous (IV) Infusion Therapy in a doctors office or facility (For IV infusion and antibiotic treatment at home, see Home Health Services. Note: Members will receive a Teladoc welcome kit explaining the benefit. 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 you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office. For a complete explanation on how the Plan is authorized tooperate when others are responsible for your injuriesplease go to: www.aetnafeds.com. We determine our allowance as follows: The amount of an out-of-network provider's charge that is eligible for coverage. In-network: $49 until the deductible is met, 30% of the $49 consult fee thereafter.Out-of-network: No benefit. 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. Items and services provided by clinical trial sponsor without charge. Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the health care provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes. You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. Microsoft is building an Xbox mobile gaming store to take on Apple Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. Ask us in writing to reconsider our initial decision. Aetna is solely responsible for the selection of network providers in your area. For current recommendations go to. Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure. The annual deductible of $2,000 for Self Only, $4,000 for Self Plus One, or $4,000 for Self and Family in-network and $5,000 for Self Only, $10,000 for Self Plus One, or $10,000 for Self and Family out-of-network, must be met before Plan benefits are paid. Enrollment in this Plan is limited: You must live or work in our geographic service area to enroll. We call this review and approval process precertification. d) The medical or health care benefits are specifically excluded from the Workers Compensation settlement or compromise. appsupports.co gathers the best news like nbc news: breaking & us news that you can use on phone. The review will not be conducted by the same person, or theirsubordinate, who made the initial decision. After 48 hours, facilities must determine if they are going to discharge or admit the patient from observation and if admitting they will be responsible to preauthorize (if out-of-network member is responsible to preauthorize inpatient stay). Here are some things to keep in mind about our prescription drug program: Mail order pharmacy. If you are enrolled in Self Plus One or Self and Family coverage, each eligible family member is also entitled to these benefits. Each prescription is limited to a maximum 90-day supply. 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. The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional". SAME DAY & NO COST COVID-19 PCR & Antibodies Testing, including FREE Enterprise Testing. We also may use your information when we pay claims or work with other insurers to pay claims. We ask for this information because its one of the ways we communicate with your insurance provider. How we get information about you -We get information about you from many sources, including from you. 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. For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. Waiting could seriously jeopardize your life or health; Waiting could seriously jeopardize your ability to regain maximum function; or. You'll get access to a wide range of benefits and services to help you be as healthy as you can be. Nothing for OTC drugs and prescription drugs approved by the FDA to treat nicotine dependence. Do not maintain as a family member on your policy: Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise). To make your request, please contact our Customer Service Department by writing Aetna, Attention: National Accounts, P.O. If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request. In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin. 20 visits per condition per member per calendar year for pulmonary rehabilitation to treat functional pulmonary disability. (or if your covered spouse is this type of judge) and you are not covered under FEHB through your spouse under #3 above, 7) Are enrolled in Part B only, regardless of your employment status, 8) Are a Federal employee receiving Workers' Compensation, 9) Are a Federal employee receiving disability benefits for six months or more. For example, if you go 19 months without Medicare Part D prescription drug coverage, your premium will always be at least 19 percent higher than what many other people pay. Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program. 2022 Luminis Health. Kansas, Most of Kansas- Allen, Anderson, Atchison, Barber,Barton, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee,Cheyenne, Clark, Clay, Cloud, Coffey, Comanche, Cowley, Crawford, Decatur,Dickinson, Doniphan, Douglas, Edwards,Elk, Ellis, Ellsworth, Finney, Ford, Franklin, Geary, Gove,Graham, Grant, Gray, Greeley, Greenwood, Hamilton, Harper, Harvey, Haskell, Hodgeman, Jackson,Jefferson, Jewell, Johnson, Kearny, Kiowa,Kingman, Labette, Lane,Leavenworth, Lincoln, Linn, Logan, Lyon, Marion, Marshall, McPherson, Meade, Miami, Mitchell, Montgomery, Morris, Morton, Nemaha, Neosho, Ness, Norton,Osage, Osborne, Ottawa, Pawnee, Phillips, Pottawatomie, Pratt, Rawlins, Reno, Republic, Rice, Riley, Rooks, Rush, Russell, Saline, Scott, Sedgwick, Seward, Shawnee, Sheridan,Sherman,Smith, Stafford, Stanton, Stevens, Sumner, Thomas, Trego, Wallace, Wabaunsee, Washington, Wichita, Wilson, Woodson, and Wyandotte counties. You can make a difference in your community. We conduct ongoing reviews of those services and supplies which are recommended or provided by health professionals to determine whether such services and supplies are covered benefits under this Plan. 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. You can get care from any licensed provider or licensed facility. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. This plan's health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. Supportive and palliative care for a terminally ill member in the home or hospice facility, including inpatient and outpatient care and family counseling, when provided under the direction of your attending Physician, who certifies the patient is in the terminal stages of illness, with a life expectancy of approximately six (6) months or less. The cookies is used to store the user consent for the cookies in the category "Necessary". We limit acronyms to ones you know. You can enroll in our Medicare Advantage plan with no additional premium. See Section 5(b). (see next page), Aetna Advantage Plan (for members who have not opted into Medicare Advantage), $2,000 (Self Only)/$4,000(Self Plus One or Self and Family), $7,500 (Self Only)/$15,000 (Self Plus One or Self and Family). If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage (TCC). 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 a Self Only enrollment, you may change to a Self Plus One or Self and Familyenrollment if you marry, give birth, or add a child to your family. Please fax W-9 along with contact name and number to the attention of Patty Kan at (925) 941-2026. Medicare Advantage (Part C) for additional details.). 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. You refers to the enrollee and each covered family member. Out-of-network:Nothing up to our Plan allowance for four (4) smoking cessation counseling sessions per quit attempt and two (2)quit attempts per year. Health education resources and accounts management tools. These may include some over-the counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. 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. Learn how to receive a copy of your records. The remaining balance of the Self Plus OneorSelf andFamily deductible can be satisfied by one or more family members. COMMERCIAL. If you are enrolling in our Aetna Medicare Advantage plan, please call us at 866-241-0262 or go to www.aetnaretireehealth.com/fehbp. Get the results of any test or procedure. We do not pay more than our allowance. Example: You pay a copayment of $10 to the pharmacy when you receive generic drugs on our formulary list. You must satisfy the deductible before your Traditional medical coverage may begin. *Approved clinical trial necessary for coverage. 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. 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/. Other choices On January 21, 2020, the Centers for Medicare &, Yes, but only for chronic lower-back pain. Your medical and claims records are confidential, General features of our Aetna Advantage Plan, Changes to the Aetna Advantage Plan Option, Section 4. Specialty care: If you have a chronic or disabling condition and lose access to your network specialist because we: you may be able to continue seeing your specialist and receive any in-network benefits for up to 90 days after you receive notice of the change. We credential Network providers according to national standards. Make sure you understand what will happen if you need surgery. cal-access.sos.ca.gov Your daytime phone number and the best time to call. If you select a different location, you may be required to choose a new date & time. 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. If you choose to access preventive care from a non-network provider, you will not qualify for 100% preventive care coverage. About Our Coalition - Clean Air California If the expense is covered in full by the primary plan, we will not pay anything. Rates are shown at the end of this brochure. It doesnt include what the public can easily see. Members must have attempted weight loss in the past without successful long-term weight reduction; and Members must have participated in and been compliant with an intensive multicomponent behavioral intervention through a combination of dietary changes and increased physical activity for 12 or more sessions occurring within 2 years prior to surgery. (See section 5(e)). 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. Annual deductible for your Aetna Advantage Plan. This notice clarifies how we use or disclose your Protected Health Information (PHI): To get a copy of this notice, just visit our member website. Get the latest health news, diet & fitness information, medical research, health care trends and health issues that affect you and your family on ABCNews.com Mail Order or CVSPharmacy, for a 31-day up to a 90-day supply per prescription or refill: $20 per preferred generic (PG) formulary drug; and, 50% plus the difference between our Plan allowance and the billed amount.

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