Connecticut HMO Disclosure qxd

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					Important information about your
health benefits – Connecticut
For the Aetna HMO plan.

Understanding your plan of                                                       Table of Contents
benefits                                                                         Understanding your plan of benefits .........................1
Aetna* health benefits plans cover most types of health                          Getting help ..................................................................1
care from a doctor or hospital. But they do not cover                               Contact us .................................................................1
everything. The plan covers recommended preventive care                             Help for those who speak another language and for
and care that you need for medical reasons. It does not                             the hearing impaired ..................................................2
cover services you may just want to have, like plastic                              Search our network for doctors, hospitals and other
                                                                                    health care providers ..................................................2
surgery. It also does not cover treatment that is not yet
widely accepted. You should also be aware that some                              Costs and rules for using your plan ............................2
services may have limits. For example, a plan may allow                             What you pay.............................................................2
                                                                                    Choose a primary care physician (PCP) .......................3
only one eye exam per year.                                                         Referrals: Your PCP will refer you to a specialist when
Not all of the information in this booklet applies to                               needed.......................................................................3
your specific plan                                                                  PCP and referral rules for Ob/Gyns .............................3
Most of the information in this booklet applies to all plans.                       Precertification: Getting approvals for services ............4
                                                                                    What to do when a dependent child is no longer
But some does not. For example, not all plans have                                  eligible for coverage ...................................................4
deductibles or prescription drug benefits. Information
                                                                                 Information about specific benefits............................4
about those topics will only apply if the plan includes those
                                                                                    Emergency and urgent care and care after office
rules.                                                                              hours .........................................................................5
Where to find information about your specific plan                                  Prescription drug benefit ............................................5
Your “plan documents” list all the details for the plan you                         Behavioral health and substance abuse benefits .........6
                                                                                    Transplants and other complex conditions ..................6
chose. Such as, what’s covered, what’s not covered and
                                                                                    Breast reconstruction benefits ....................................6
the specific amounts you will pay for services. Plan                                Religious exemption ...................................................6
document names vary. They may include a Schedule of
                                                                                 Knowing what is covered ............................................7
Benefits, Certificate of Coverage, Group Agreement,                                We check if it’s “medically necessary” ........................7
Group Insurance Certificate, Group Insurance Policy and/or                         We study the latest medical technology .....................7
any riders and updates that come with them.                                        We post our findings on www.aetna.com ..................7
If you can’t find your plan documents, call Member                                 We can help when more serious care is suitable.........7
Services to ask for a copy. Use the toll-free number on your                     What to do if you disagree with us ............................8
Aetna ID card.                                                                     Complaints, appeals and external review....................8
                                                                                 Member rights & responsibilities ................................9
                                                                                   Know your rights as a member ..................................9
Getting help                                                                       Making medical decisions before your procedure .......9
                                                                                   Learn about our quality management programs.........9
Contact us                                                                         We protect your privacy .............................................9
Member Services can help with your questions. To contact                           Anyone can get health care......................................10
                                                                                   How we use information about your race, ethnicity
Member Services, call the toll-free number on your ID card.
                                                                                   and the language you speak ....................................10
You can also send Member Services an e-mail. Just go to                            Your rights to enroll later if you decide not to enroll
your secure Aetna Navigator® member website at                                     now .........................................................................10
www.aetna.com. Click on “Contact Us” after you log                                 Medical Loss Ratios ..................................................10
on.


* Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. Health benefits plans
  are provided and/or administered by Aetna Health Inc. and/or Aetna Life Insurance Company (Aetna).



www.aetna.com
01.28.325.1-CT (8/11)                                                    1
Member Services can help you:                                      ■   Call us at the toll-free number on your Aetna ID card, If
■   Understand how your plan works or what you will pay                you don’t have your card you can call us at
                                                                       1-888-87-AETNA (1-888-872-3862).
■   Get information about how to file a claim
                                                                   For up-to-date information about how to find inpatient
■   Get a referral
                                                                   and outpatient services, partial hospitalization and other
■   Find care outside your area                                    behavioral health care services, please follow the
■   File a complaint or appeal                                     instructions above. If you do not have Internet access and
■   Get copies of your plan documents                              would like a printed list of providers, please contact
                                                                   Member Services at the toll-free number on your Aetna ID
■   Connect to behavioral health services (if included in
                                                                   card to ask for a copy.
    your plan)
                                                                   Our online directory is more than just a list of doctor’s
■   Find specific health information
                                                                   names and addresses. It also includes information about
■   Learn more about our Quality Management program                where the physician attended medical school, board
■   And more                                                       certification status, language spoken, gender and more.
                                                                   You can even get driving directions to the office. If you
Help for those who speak another                                   don’t have Internet access, you can call Member Services
language and for the hearing impaired                              to ask about this information.
Do you need help in another language? Member Services
representatives can connect you to a special line where you        Costs and rules for using your
can talk to someone in your own language. You can also
get interpretation assistance for registering a complaint or
                                                                   plan
appeal.                                                            What you pay
Language hotline – 1-888-982-3862 (140 languages are               You will share in the cost of your health care. These are
available. You must ask for an interpreter.)                       called “out-of-pocket” costs. Your plan documents show
TDD 1-800-628-3323 (hearing impaired only)                         the amounts that apply to your specific plan. Those costs
                                                                   may include:
Ayuda para las personas que hablan otro                            ■   Copay – A fixed amount (for example, $15) you pay
idioma y para personas con                                             for covered health care service. You usually pay this
impedimentos auditivos                                                 when you receive the service. The amount can vary by
¿Necesita ayuda en otro idioma? Los representantes de                  the type of service. For example, the copay for your
Servicios al Miembro le pueden conectar a una línea                    primary doctor’s office visit may be different than a
especial donde puede hablar con alguien en su                          specialist’s office visit.
propio idioma. También puede obtener asistencia de un                  ■   Inpatient Hospital Copay – This copay applies when
intérprete para presentar una queja o apelación.                           you are a patient in a hospital.
Línea directa: 1-888-982-3862 (Tenemos 140 idiomas                     ■   Emergency Room Copay – This is the amount you
disponibles. Debe pedir un intérprete.)                                    pay when you go to the emergency room. If you are
TDD 1-800-628-3323 (sólo para personas con                                 admitted to the hospital within 24 hours, you won’t
impedimentos auditivos)                                                    have to pay it.
                                                                   ■   Coinsurance – Your share of the costs of a covered
Search our network for doctors,                                        service. Coinsurance is calculated as a percent (for
hospitals and other health care providers                              example, 20%) of the allowed amount for the service.
It’s important to know which doctors are in our network.               For example, if the health plan’s allowed amount for an
That’s because this health plan only lets you visit doctors,           office visit is $100 and you’ve met your deductible,
hospitals and other health care providers, such as labs, if            your coinsurance payment of 20% would be $20. The
they are in our network.                                               health plan pays the rest of the allowed amount.
Here’s how you can find out if your health care provider is
in our network.
■   Log on to your secure Aetna Navigator member
    website at www.aetna.com. Follow the path to find a
    doctor and enter your doctor’s name in the search field.




                                                               2
■   Deductible – Some plans include a deductible. This is          The name of your PCP will appear on your Aetna ID card.
    the amount you owe for health care services before             You may change your selected PCP at any time. If you
    your health plan begins to pay. For example, if your           change your PCP, you will receive a new ID card.
    deductible is $1,000, your plan won’t pay anything
    until you have paid $1,000 for any covered health care         Referrals: Your PCP will refer you to a
    services that are subject to the deductible. The               specialist when needed
    deductible may not apply to all services. Other                If you need specialty care, your PCP will give you a referral
    deductibles may apply at the same time:                        to a specialist who participates in the Aetna network. A
Your costs when you go outside the network                         “referral” is a written request for you to see another
HMOs are network-only plans. That means, the plan covers           doctor. Some doctors can send the referral electronically to
health care services only when provided by a doctor who            your specialist. There’s no paper involved!
participates in the Aetna network. If you receive services         Talk to your doctor to understand why you need to see a
from an out-of-network doctor or other health care                 specialist. And remember to always get the referral before
provider, you will have to pay all of the costs for the            you receive the care.
services.
                                                                   Remember these points about referrals:
See “Emergency and urgent care and care after office
hours” for more.
                                                                   ■   You do not need a referral for emergency care.
Going in network just makes sense!
                                                                   ■   If you do not get a referral when required, you may
■ We have negotiated discounted rates for you.                         have to pay the bill yourself. If your plan lets you go
                                                                       outside the network, the plan will pay it as an out-of-
■   In-network doctors and hospitals won’t bill you for                network benefit.
    costs above our rates for covered services.
                                                                   ■   Your specialist might recommend treatment or tests
■   You are in great hands with access to quality care from            that were not on the original referral. In that case, you
    our national network.                                              may need to get another referral from your PCP for
                                                                       those services.
Choose a primary care physician (PCP)
                                                                   ■   Women can go to an Ob/Gyn without a referral. See
You must pick a primary care physician, or “PCP,” who can
                                                                       “PCP and referral rules for Ob/Gyns” below.
get to know your health care needs and help you better
manage your health care. You can designate any primary             ■   Referrals are valid for one year as long as you are still a
care provider who participates in the Aetna network and                member of the plan. Your first visit must be within 90
who is available to accept you or your family members. If              days of the referral issue date.
you do not pick a PCP, your benefits may be limited or we          ■   You can get a special referral to go outside the Aetna
may select a PCP for you.                                              network if a network specialist is not available for your
A PCP is the doctor you go to when you need health care.               health care needs.
If it’s an emergency, you don’t have to call your PCP first.       Referrals within physician groups
This one doctor can coordinate all your care. Your PCP will        Some PCPs are part of a larger group of doctors. These
perform physical exams, order tests and screenings and             PCPs will usually refer you to another doctor within that
help you when you’re sick. Your PCP will also refer you to         same group. If this group cannot meet your medical needs,
a specialist when needed.                                          you can ask us for a coverage exception to go outside this
A female member may choose an Ob/Gyn as her PCP. You               group. You may also need to precertify these services. And
may also choose a pediatrician for your child(ren)’s PCP.          you may need permission from the physician group as
Your OB/Gyn acting as your PCP will provide the same               well.
services and follow the same guidelines as any other PCP.
They will issue referrals to other doctors (if your plan           PCP and referral rules for Ob/Gyns
requires referrals) and they will get all required approvals       A female member can choose an Ob/Gyn as her PCP.
and comply with any preapproved treatment plans. See               Women can also go to any obstetrician or gynecologist
the sections about referrals and precertification for more         who participates in the Aetna network without a referral
about those requirements.                                          or prior authorization. Visits can be for checkups, including
Tell us who you chose to be your PCP                               breast exams, mammograms and Pap smears, and for
You may choose a different PCP from the Aetna network              obstetric or gynecologic problems.
for each member of your family. Enter the name of the
PCP you have chosen on your enrollment form. Or, call
Member Services after you enroll to tell us your selection.

www.aetna.com
                                                               3
Also, an Ob/Gyn can give referrals for covered obstetric or             ■   Becomes covered under a group health plan through
gynecologic services just like a PCP. Just follow your plan’s               the dependent’s own employment
normal rules. Your Ob/Gyn might be part of a larger                     ■   Attains the age of 26
physician’s group. If so, any referral will be to a specialist in
                                                                        If a child dependent’s coverage is terminated, there is an
that larger group. Check with the Ob/Gyn to see if the
                                                                        option under the plan to continue the child’s coverage for
group has different referral policies.
                                                                        the longer of:
Precertification: Getting approvals for                                     1. The end of the month following the month in which
                                                                               the child attains the limiting age, or
services
Sometimes we will pay for care only if we have given an                     2. For the period set forth in COBRA/state continuation
approval before you get it. We call that “precertification.”            Since most often the period for COBRA/state continuation
Precertification is usually limited to more serious care like           (option 2) will be the longer of the two periods, we will
surgery or being admitted to a hospital or skilled nursing              process the termination of the dependent child’s coverage
facility. When you get care from a doctor in the Aetna                  effective at the end of the month in which the dependent
network, your doctor takes care of precertification. But if             child’s coverage termination event occurred. COBRA/state
you get your care outside our network, you must call us                 continuation will begin thereafter.
for precertification when that’s required. Your plan                    However, if you choose to elect option (1) as described
documents list all the services that require you to get                 above, you must notify your employer. Your employer will
precertification. If you don’t, you will have to pay for all or         then notify us so that we can process your election
a larger share of the cost of the service. Even with                    appropriately. Please note: If you elect option (1),
precertification, if you receive services from an out-of-               COBRA/state continuation will not be available at the end
network provider, you will usually pay more.                            of that period.
Call the number shown on your Aetna ID card to begin                    The options and procedures described above also apply to
the process. You must get the approval before you receive               an employee’s spouse upon divorce, court ordered
the care.                                                               annulment or separation.
Precertification is not required for emergency services.                If your dependent child is handicapped on the date
                                                                        coverage would otherwise terminate, he/she may be able
What we look for when reviewing a precertification
                                                                        to continue coverage if you provide documentation of this
request
                                                                        status within 31 days of the date on which the child’s
First, we check to see that you are still a member. And we
                                                                        coverage would have terminated in the absence of the
make sure the service is considered medically necessary for
                                                                        handicap.
your condition. We also check that the service and place
requested to perform the service is cost effective. If we               You can get the forms you need to continue coverage by
know of a treatment or place of service that is just as                 calling Member Services at the toll-free number on your
effective but costs less, we may talk to you and your                   member ID card. Complete and return the forms within 31
doctor about it. We also look to see if you qualify for one             days of the date on which the child’s coverage would have
of our case management programs. If so, one of our                      terminated in the absence of the handicap in order to
nurses may call to tell you about it and help you                       continue coverage; otherwise, your dependent’s coverage
understand your upcoming procedure.                                     will end as described above.
Precertification does not, however, verify if you have                  If your dependent is not handicapped and you would like
reached any plan dollar limits or visit maximums for the                information on continuing coverage for him or her within
service requested. That means precertification is not a                 our service area, please contact your benefits administrator.
guarantee that the service will be covered.
                                                                        Information about specific
What to do when a dependent child is                                    benefits
no longer eligible for coverage
Connecticut law allows special provisions for dependent                 Emergency and urgent care and care
children who are no longer eligible for coverage due to                 after office hours
any of the following reasons:                                           An emergency medical condition means your symptoms
■   The child marries                                                   are sudden and severe. If you don’t get help right away, an
■   Ceases to be a resident of the state (does not apply to             average person with average medical knowledge will
    a dependent child under age 19 or a full-time student               expect that you could die or risk your health. For a
    attending an accredited institution of higher education)            pregnant woman, that includes her unborn child.



                                                                    4
Emergency care is covered anytime, anywhere in the                     Generic drugs usually sell for less; so many plans give you
world. If you need emergency care, follow these                        incentives to use generics. That doesn’t mean you can’t
guidelines:                                                            use a brand-name drug, but you’ll pay more for them.
■   Call 911 or go to the nearest emergency room. If a                 You’ll not only pay your normal share of the cost, you’ll
    delay would not risk your health, call your doctor or              also pay the difference in the two prices.
    PCP.                                                               We may also encourage you to use certain drugs
■   Tell your doctor or PCP as soon as possible afterward. A           Some plans encourage you to buy certain prescription
    friend or family member may call on your behalf.                   drugs over others. The plan may even pay a larger share
■   Emergency care services do not require precertification.           for those drugs. We list those drugs in the Aetna Preferred
                                                                       Drug Guide (also known as a “drug formulary”). This list
How we cover out-of-network emergency care                             shows which prescription drugs are covered on a preferred
You are covered for emergency and urgently needed care.                basis. It also explains how we choose medications to be on
You have this coverage while you are traveling or if you are           the list.
near your home. That includes students who are away at
school. When you need care right away, go to any doctor,               When you get a drug that is not on the preferred drug list,
walk-in clinic, urgent care center or emergency room.                  your share of the cost will usually be more. Check your
                                                                       plan documents to see how much you will pay. If your plan
We’ll review the information when the claim comes in. If               has an “open formulary,” that means you can use those
we think the situation was not urgent, we might ask you                drugs, but you’ll pay the highest copay under the plan. If
for more information and may send you a form to fill out.              your plan has a “closed formulary,” those drugs are not
Please complete the form, or call Member Services to give              covered.
us the information over the phone.
                                                                       Drug Manufacturer Rebates
When you have an emergency (for example: emergency                     Drug manufacturers may give us rebates when our
room visit after a car accident), we will pay the bill as if you       members buy certain drugs. While those rebates for the
got care in network. You pay your plan's copayments,                   most part apply to drugs on the Preferred Drug List, they
coinsurance, and deductibles. Under federal health care                may also apply to drugs not on the Preferred Drug List.
reform (Affordable Care Act), the government will allow                But, in any case, in plans where you pay a percent of the
some plans an exception to this rule. Contact Aetna if your            cost, your share of the cost is based on the price of the
provider asks you to pay more. We will help you determine              drug before any rebate is received by Aetna.
if you need to pay that bill.
                                                                       In plans where you pay a percent of the cost instead of a
Follow-up care                                                         flat dollar amount, you may pay more for a drug on the
You may need to follow up with a doctor after your                     Preferred Drug List than for a drug not on the list.
emergency. For example, you’ll need a doctor to take out
                                                                       Mail-order and specialty-drug services are from
stitches, remove a cast or take another set of X-rays to see
                                                                       Aetna-owned pharmacies
if you’ve healed. Your PCP should coordinate all follow-up
                                                                       Aetna Rx Home Delivery and Aetna Specialty Pharmacy are
care. You will need a referral for follow-up care that is not
                                                                       pharmacies that Aetna owns. These pharmacies are for-
performed by your PCP. You may also need to precertify
                                                                       profit entities.
the services if you go outside the network.
                                                                       You might not have to stick to the list
After-hours care — available 24/7
                                                                       If it is medically necessary for you to use a drug that’s not
Call your doctor anytime if you have medical questions or
                                                                       on your plan’s preferred drug list, you or your doctor (or
concerns. Your doctor should have an answering service if
                                                                       pharmacist in the case of antibiotics and pain medicines)
you call after the office closes. You can also go to an
                                                                       can ask us to make an exception. Check your plan
urgent care center, which may have limited hours. To find
                                                                       documents for details.
a center near you, log on to www.aetna.com and search
our list of doctors and other health care providers. Check             You may have to try one drug before you can try
your plan documents to see how much you must pay for                   another
urgent care services.                                                  Step therapy means you have to try one or more
                                                                       “prerequisite” drugs before a “step-therapy” drug will be
Prescription drug benefit                                              covered. The preferred drug list includes step-therapy
                                                                       drugs. Your doctor might want you to skip one of these
Some plans encourage generic drugs over brand-
                                                                       drugs for medical reasons. If so, you or your doctor (or
name drugs
                                                                       pharmacist in the case of antibiotics and pain medicines)
A generic drug is the same as a brand-name drug in dose,
                                                                       can ask for a medical exception.
use and form. They are FDA approved and safe to use.


www.aetna.com
                                                                   5
Some drugs are not covered at all                                  For more information on either of these prevention
Prescription drug plans do not cover drugs that don’t need         programs and how to enroll in the programs, ask Member
a prescription. Your plan documents might also list specific       Services for the phone number of your local Care
drugs that are not covered. You cannot get a medical               Management Center.
exception for these drugs.
New drugs may not be covered
                                                                   Transplants and other complex
Your plan may not cover drugs that we haven’t reviewed             conditions
yet. You or your doctor may have to get our approval to            Our National Medical Excellence Program® (NME) is for
use one of these new drugs.                                        members who need a transplant or have a condition that
Get a copy of the preferred drug list                              can only be treated at a certain hospital. You usually need
The Aetna Preferred Drug Guide is posted to our website            to use an Aetna Institutes of ExcellenceTM hospital to get
at www.aetna.com/formulary/. If you don’t use the                  coverage for the treatment. Some plans won’t cover the
Internet, you can ask for a printed copy. Just call Member         service if you don’t. We choose hospitals for the NME
Services at the toll-free number on your Aetna ID card. We         program based on their expertise and experience with
are constantly adding new drugs to the list. Look online or        these services. We also follow any state rules when
call Member Services for the latest updates.                       choosing these hospitals.
Have questions? Get answers!                                       Breast reconstruction benefits
Ask your doctor about specific medications. Call Member
Services (at the number on your ID card) to find out how           Notice Regarding Women’s Health and Cancer Rights
your plan pays for them. Your plan documents also spell            Act
out what’s covered and what is not.                                Under this health plan, as required by the Women’s Health
                                                                   and Cancer Rights Act of 1998, coverage will be provided
Behavioral health and substance abuse                              to a person who is receiving benefits in connection with a
                                                                   mastectomy and who elects breast reconstruction in
benefits
                                                                   connection with the mastectomy for:
You must use behavioral health professionals who are in
                                                                   (1) all stages of reconstruction of the breast on which a
the Aetna network.
                                                                       mastectomy has been performed;
Here’s how to get behavioral health services
                                                                   (2) surgery and reconstruction of the other breast to
■   Emergency services – call 911.                                     produce a symmetrical appearance;
■   Call the toll-free Behavioral Health number on your            (3) prostheses; and
    Aetna ID card.
                                                                   (4) treatment of physical complications of all stages of
■   If no other number is listed, call Member Services.                mastectomy, including lymph edemas.
■   If you’re using your employer’s or school’s EAP program,       This coverage will be provided in consultation with the
    the EAP professional can help you find a behavioral            attending physician and the patient, and will be provided
    health specialist.                                             in accordance with the plan design, limitations, copays,
Read about behavioral health provider safety                       deductibles, and referral requirements, if any, as outlined in
We want you to feel good about using the Aetna network             your plan documents.
for behavioral health services. Visit                              If you have any questions about our coverage of
www.aetna.com/docfind and click the “Get info on                   mastectomies and reconstructive surgery, please contact
Patient Safety and Quality” link. No Internet? Call Member         the Member Services number on your ID card.
Services instead. Use the toll-free number on your Aetna ID        For more information, you can visit this U.S. Department of
card to ask for a printed copy.                                    Health and Human Services website, www.cms.hhs.gov/
Behavioral health programs to help prevent                         HealthInsReformforConsume/06_TheWomen’sHealth
depression                                                         andCancerRightsAct.asp#TopOfPage and this U.S.
Aetna Behavioral Health offers two prevention programs             Department of Labor website:
for our members:                                                   www.dol.gov/ebsa/consumer_info_health.html.
■   Beginning Right® Depression Program: Perinatal
    Depression Education, Screening and Treatment Referral         Religious Exemption
    and                                                            As permitted under Connecticut law, an insurer may issue
■   SASDA: Identification and Referral of Substance Abuse          to a religious employer, a policy that excludes coverage for
    Screening for Adolescents with Depression and/or               infertility treatment that is contrary to the religious
    Anxiety Prevention                                             employer’s beliefs. Some of these treatments may include:



                                                               6
■   Ovulation induction (OI)                                         department with questions. Contact Member Services
■   Intrauterine insemination                                        either online or at the phone number on your Aetna ID
                                                                     card for the appropriate address and phone number.
■   In-vitro fertilization (IVF)
■   Embryo transfer                                                  We study the latest medical technology
■   Gamete intra-fallopian transfer (GIFT)                           To help us decide what is medically necessary, we may look
■   Zygote intra-fallopian transfer (ZIFT)                           at scientific evidence published in medical journals. This is
■   Low tubal ovum transfer                                          the same information doctors use. We also make sure the
■   Uterine embryo lavage                                            product or service is in line with how doctors, who usually
                                                                     treat the illness or injury, use it. Our doctors may use
Please refer to your plan administrator for specifics                nationally recognized resources like The Milliman Care
regarding your benefits.                                             Guidelines.
                                                                     We also review the latest medical technology, including
Knowing what is covered                                              drugs, equipment — even mental health treatments. Plus,
You can avoid receiving an unexpected bill with a simple             we look at new ways to use old technologies. To make
call to Member Services. You can find out if your                    decisions, we may:
preventive care service, diagnostic test or other treatment          ■   Read medical journals to see the research. We want to
is a covered benefit — before you receive care — just by                 know how safe and effective it is.
calling the toll-free number on your ID card.                        ■   See what other medical and government groups say
Here are some of the ways we determine what is covered:                  about it. That includes the federal Agency for Health
                                                                         Care Research and Quality.
We check if it’s “medically necessary”                               ■   Ask experts.
Medical necessity is more than being ordered by a doctor.
                                                                     ■   Check how often and how successfully it has been
“Medically necessary” means your doctor ordered a
                                                                         used.
product or service for an important medical reason. It
might be to help prevent a disease or condition. Or to               We publish our decisions in our Clinical Policy Bulletins.
check if you have one. Or it might be to treat an injury or
illness.                                                             We post our findings on www.aetna.com
The product or service:                                              After we decide if a product or service is medically
                                                                     necessary, we write a report about it. We call the report a
■   Must meet a normal standard for doctors
                                                                     Clinical Policy Bulletin (CPB).
■   Must be the right type in the right amount for the right
                                                                     CPBs tell if we view a product or service as medically
    length of time and for the right body part. It also has to
                                                                     necessary. They also help us decide whether to approve a
    be known to help the particular symptom.
                                                                     coverage request. But your plan may not cover everything
■   Cannot be for the member’s or the doctor’s                       that our CPBs say is medically necessary. Each plan is
    convenience                                                      different, so check your plan documents.
■   Cannot cost more than another service or product that            CPBs are not meant to advise you or your doctor on your
    is just as effective                                             care. Only your doctor can give you advice and treatment.
Only medical professionals can deny coverage if the reason           Talk to your doctor about any CPB related to your
is medical necessity. We do not give financial incentives or         coverage or condition.
otherwise to Aetna employees for denying coverage.                   You and your doctor can read our CPBs on our website at
Sometimes the review of medical necessity is handled by a            www.aetna.com under “Individuals & Families.” No
physicians’ group. Those groups might use different                  Internet? Call Member Services at the toll-free number on
resources than we do.                                                your ID card. Ask for a copy of a CPB for any particular
If we deny coverage, we’ll send you and your doctor a                product or service.
letter. The letter will explain how to appeal the denial. You
have the same right to appeal if a physician’s group denied          We can help when more serious care is
coverage for medical necessity. You can call Member                  suitable
Services to ask for a free copy of the criteria we use to            In certain cases, we review a request for coverage to be
make coverage decisions. Or visit www.aetna.com/                     sure the service or supply is consistent with established
about/cov_det_policies.html to read our policies.                    guidelines. Then we follow up. We call this “utilization
Doctors can write or call our Patient Management                     management review.”


www.aetna.com
                                                                 7
It’s a three step process:                                             If you’re not satisfied after talking to a Member Services
    First, we begin this process if your hospital stay lasts           representative, you can ask that your issue be sent to the
    longer than what was approved. We verify that it is                appropriate department.
    necessary for you to still be in the hospital. We look at          If you don’t agree with a denied claim, you can file
    the level and quality of care you are getting.                     an appeal. To file an appeal, follow the directions in the
    Second, we begin planning your discharge. This process             letter or explanation of benefits statement that explains
    can begin at any time. We look to see if you may                   that your claim was denied. The letter also tells you what
    benefit from any of our programs. We might have a                  we need from you and how soon we will respond.
    nurse case manager follow your progress. Or we might               Get a review from someone outside Aetna
    recommend that you try a wellness program after you                  Connecticut External Review – After you have
    get back home.                                                       exhausted the Aetna internal appeal process described
    Third, after you are home, we may review your case.                  above, you or a provider acting on your behalf and with
    We may look over your medical records and claims from                your consent have the right to appeal to the
    your doctors and the hospital. We look to see that you               Connecticut Insurance Department if we have denied
    got appropriate care. We also look for waste or                      coverage because the services are not medically
    unnecessary costs.                                                   necessary, experimental or investigational, cosmetic or
We follow specific rules to help us make your health a top               custodial under the terms of your plan. Your appeal to
concern:                                                                 the Insurance Department would have to be filed within
                                                                         60 days after you receive notice of a final determination
■   Aetna employees are not compensated based on
                                                                         from Aetna. In an emergency or life-threatening
    denials of coverage.
                                                                         situation, you or a provider acting on your behalf and
■   We do not encourage denials of coverage. In fact, our                with your consent may make a request to the
    utilization review staff is trained to focus on the risks of         Connecticut Insurance Department for an expedited
    members not adequately using certain services.                       external appeal without exhausting our internal appeal
Where such use is appropriate, our Utilization                           process.
Review/Patient Management staff uses nationally                           Aetna External Review – As an alternative, you can
recognized guidelines and resources, such as The Milliman                 ask Aetna to coordinate an outside review if you’re not
Care Guidelines® to guide these processes. When provider                  satisfied after going through our internal appeals
groups, such as independent practice associations, are                    process. Follow the instructions on our response to your
responsible for these steps, they may use other criteria that             appeal. Call Member Services to ask for an External
they deem appropriate. Utilization Review/Patient                         Review Form or log on to
Management policies may vary as a result of state laws.                   www.aetna.com/individuals-families-health-
                                                                          insurance/member-guidelines/ext_review.html.
What to do if you disagree                                             If your case qualifies, an Independent Review Organization
with us                                                                (IRO) will assign it to an outside expert. The expert will be a
                                                                       doctor or other professional who specializes in that area or
Complaints, appeals and external review                                type of dispute. You should have a decision within 45
Please tell us if you are not satisfied with a response you            calendar days of the request.
received from us or with how we do business.                           We will follow the external reviewer’s decision. We will also
The complaint and appeal processes can be different                    pay the cost of the review.
depending on your plan and where you live. Some states                 A “rush” review may be possible
have laws that include their own processes. But these state            If your doctor thinks you cannot wait 45 days, ask for an
laws don’t apply to many plans we administer. So it’s best             “expedited review.” That means we will make our decision
to check your plan documents or talk to someone in                     more quickly.
Member Services to see how it works for you.
Call Member Services to file a verbal complaint or to
ask for the appropriate address to mail a written
complaint. The phone number is on your Aetna ID card.
You can also e-mail Member Services through the secure
member website.




                                                                   8
Member rights &                                                      We protect your privacy
responsibilities                                                     We consider your personal information to be private. Our
                                                                     policies help us protect your privacy. By “personal
Know your rights as a member                                         information,” we mean information about your physical
                                                                     condition, the health care you receive and what your
You have many legal rights as a member of a health plan.
                                                                     health care costs. Personal information does not include
You also have many responsibilities. You have the right to
                                                                     what is available to the public. For example, anyone can
suggest changes in our policies and procedures, including
                                                                     find out what your health plan covers or how it works. It
our Member Rights and Responsibilities.
                                                                     also does not include summarized reports that do not
Below are just some of your rights. We also publish a list of        identify you.
rights and responsibilities on our website. Visit
                                                                     Below is a summary of our privacy policy. For a copy of our
www.aetna.com/individuals-families-health-
                                                                     actual policy, go to www.aetna.com. You’ll find the
insurance/member-guidelines/member-rights.html
                                                                     “Privacy Notices” link at the bottom of the page. You can
to view the list. You can also call Member Services at the
                                                                     also write to:
number on your ID card to ask for a printed copy.
                                                                     Aetna Legal Support Services Department
Making medical decisions before your                                 151 Farmington Avenue, W121
procedure                                                            Hartford, CT 06156
An “advanced directive” tells your family and doctors what           Summary of the Aetna privacy policy
to do when you can’t tell them yourself. You don’t need              We have policies and procedures in place to protect your
an advanced directive to receive care. But you have the              personal information from unlawful use and disclosure. We
right to create one. Hospitals may ask if you have an                may share your information to help with your care or
advanced directive when you are admitted.                            treatment and administer our health plans and programs.
                                                                     We use your information internally, share it with our
There are three types of advanced directives:
                                                                     affiliates, and we may disclose it to:
■   Durable power of attorney – name the person you
                                                                     ■   Your doctors, dentists, pharmacies, hospitals and other
    want to make medical decisions for you.
                                                                         caregivers
■   Living will – spells out the type and extent of care you
                                                                     ■   Those who pay for your health care services. That can
    want to receive.
                                                                         include health care provider organizations and
■   Do-not-resuscitate order – states that you don’t want                employers who fund their own health plans or who
    CPR if your heart stops or a breathing tube if you stop              share the costs.
    breathing.
                                                                     ■   Other insurers
You can create an advanced directive in several ways:
                                                                     ■   Third-party administrators
■   Ask your doctor for an advanced directive form.
                                                                     ■   Vendors
■   Pick up a form at state or local offices on aging, bar
                                                                     ■   Consultants
    associations, legal service programs, or your local health
    department.                                                      ■   Government authorities and their respective agents
■   Work with a lawyer to write an advanced directive.               These parties must also keep your information private.
                                                                     Doctors in the Aetna network must allow you to see your
■   Create an advanced directive using computer software
                                                                     medical records within a reasonable time after you ask for
    designed for this purpose.
                                                                     it.
Source: American Academy of Family Physicians. Advanced
Directives and Do Not Resuscitate Orders. September 2010.            Some of the ways we use your personal information
Available at http://familydoctor.org/online/famdocen/home/           include:
pat-advocacy/endoflife/003.html. Accessed December 6, 2010.
                                                                     ■   Paying claims
Learn about our quality management                                   ■   Making decisions about what to cover
programs                                                             ■   Coordinating payments with other insurers
We make sure your doctor provides quality care for you               ■   Preventive health, early detection, and disease and case
and your family. To learn more about these programs, go                  management
to our website at www.aetna.com/individuals-families-
health-insurance/member-guidelines/health-care-
quality.html. You can also call Member Services to ask for
a printed copy. See “Contact Us” on page 1.

www.aetna.com
                                                                 9
We consider these activities key for the operation of our                         spouse or children and other dependents. If that happens,
health plans. We usually will not ask if it’s okay to share                       you must apply within 31 days after your coverage ends
your information unless the law requires us to. We will ask                       (or after the employer stops contributing to the other
your permission to disclose personal information if it is for                     coverage).
marketing purposes. Our policies include how to handle                            When you have a new dependent
requests for your information if you are unable to give                           Getting married? Having a baby? A new dependent
consent.                                                                          changes everything. And you can change your mind. If you
                                                                                  chose not to enroll during the normal open enrollment
Anyone can get health care                                                        period, you can enroll within 31 days after a life event.
We do not consider your race, disability, religion, sex,                          That includes marriage, birth, adoption or placement for
sexual orientation, health, ethnicity, creed, age or national                     adoption. Talk to your benefits administrator for more
origin when giving you access to care. Network providers                          information, to request special enrollment or for more
are contractually obligated to the same.                                          information.
We must comply with these laws:                                                   Getting proof that you had previous coverage
■   Title VI of the Civil Rights Act of 1964                                      Sometimes when you apply for health coverage, the
■   Age Discrimination Act of 1975                                                insurer may ask for proof that you were covered before.
                                                                                  This helps determine if you are eligible for their plan. Your
■   Americans with Disabilities Act
                                                                                  plan sponsor may have contracted with us to issue a
■   Laws that apply to those who receive federal funds                            certificate. Ask us for a Certificate of Prior Health Coverage
■   All other laws that protect your rights to receive health                     anytime you want to check the status of your coverage. If
    care                                                                          you lost your coverage, you have 24 months to make this
                                                                                  request. Just call Member Services at the toll-free number
How we use information about your                                                 on your ID card.
race, ethnicity and the language you
speak                                                                             Medical Loss Ratios
You choose if you want to tell us your race/ethnicity and                         The medical loss ratio is defined as the ratio of incurred
preferred language. We’ll keep that information private.                          claims to earned premium for the prior calendar year for
We use it to help us improve your access to health care.                          managed care plans issued in Connecticut. Claims shall be
We also use it to help serve you better. See “We protect                          limited to medical expenses for services and supplies
your privacy” to learn more about how we use and protect                          provided to enrollees and shall not include expenses for
your private information. See also “Anyone can get health                         stop loss, reinsurance, enrollee educational programs or
care.”                                                                            other cost containment programs or features.
                                                                                  Aetna Health Inc.
Your rights to enroll later if you decide                                           For Medical 87.5%
not to enroll now                                                                   Dental Stand alone 101.74%
When you lose your other coverage                                                 Aetna Life Insurance Company (ALIC)
You might choose not to enroll now because you already                              For Aetna Life Insurance Company Medical 82.75%
have health insurance. You may be able to enroll later if                           Dental Stand alone 79.7%
you lose that other coverage or if your employer stops
contributing to the cost. This includes enrolling your




Aetna is committed to Accreditation by the National Committee for Quality Assurance (NCQA) as a means of demonstrating a commitment to
continuous quality improvement and meeting customer expectations. A complete listing of health plans and their NCQA status can be found on the
NCQA website located at reportcard.ncqa.org.
To refine your search, we suggest you search these areas: Managed Behavioral Healthcare Organizations – for behavioral health accreditation;
Credentials Verification Organizations – for credentialing certification; Health Insurance Plans – for HMO and PPO health plans; Physician and
Physician Practices – for physicians recognized by NCQA in the areas of heart/stroke care, diabetes care, back pain and medical home. Providers who
have been duly recognized by the NCQA Recognition Programs are annotated in the provider listings section of this directory.
Providers, in all settings, achieve recognition by submitting data that demonstrates they are providing quality care. The program constantly assesses key
measures that were carefully defined and tested for their relationship to improved care; therefore, NCQA provider recognition is subject to change.
Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice.
Aetna does not provide care or guarantee access to health services. For up-to-date information, please visit our DocFind® directory at www.aetna.com
or, if applicable, visit the NCQA’s new top-level recognition listing at recognition.ncqa.org.



                                                                           10
Notes
Notes

				
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