HomeMy WebLinkAboutContract 45772 (2)s
.. ,L. __ ,�. i „ ., .
?.
, �` :ti �`� � �!:
�`\ ' itl
AETNA HEALTH INC.
(TEXAS)
2013 MEDICARE ADVANTAGE HMO
GROUP AGREEMENT COVER SHEET
Contract Holder:
Contract Holder Number:
HMO Benefit:
Effective Date:
Term of Group A�reement:
Premium Due Dates:
Plan Pr�emium Rates:
Right to Audit
NIE HMO GA (Y2013)
City Of Foi•t Worth
457106
020
rr:��j■
MEDICARE 0 SPECIAL PLAN Benefits
Package
with Medicare Prescription Drug benefits
12:01 a.m. on January 1, 2013
The Initial Term shall be: Froin January 1, 2013
tlu•ough Decembei• 31, 2013. Thereafter�,
Subsequent Terms shall be: From Januaiy lst
tlu�ough December 31st.
The Group Agi•eement Effective Date and the lst
day of each succeeding calendai• month.
Please refer to the rate/financial e�ibit, financial
caveats document and/or final renewal
communication (and any amendments made
thereto) issued by Aetna in comlection with this
Group Agreement and attached hereto as E�ibit B
("Rate Documents") for applicable rates.
Aetna agrees that Contract Holder shall, until the
expiration of one (1) year after final payment under
this agreement, have access to and the right to
exanline any directly pet�tinent boolcs, documents,
papers, and t�ecords r•egarding Contract Holdel•'s
pi•emium, participant census data, and billing under
this Agreement. Aetna agi•ees that Contr•act Holdei•
shall have access during noi•mal wot•king houi•s to
all necessaty Aetna facilities and shall be provided
adequate and appropriate workspace in order to
conduct audits in coinpliance with this provision.
�_ �, .�
�.
►: �
r } -
7.
:
.
- �
, _ l,
Contract Holder shall give Aetna reasonable
advance notice of intended audits.
Term of Rates:
Governing Law:
Notice Address for:
and to Contract Holder at:
From January 1, 2013 to December 31, 2013.
These rates are subject to adjustments based on final
regulatory determinations.
Federal law and, to the extent not pt•eernpted, the
laws of the State of Texas.
1425 Union Meeting Road
Post Office Box 1445
Blue Bell, PA 19422
City Of Fort Worth
Assistant City Manager for Human Resources
with copy to
Human Resources Department
Attn - Beneiits
1000 Throckmorton
Fort Worth, TX 76102
The parties shall attempt in good faith to resolve any dispute arising out of or� relating to this
Agreement promptly by negotiation between executives who have authority to settle the
controversy and who are at a higher level of management than the persons with direct
responsibility for administration of the contract. Any party may give the othet• pat�ty written
notice of any dispute not resolved in the normal course of business, including the prescribed
period to cure alleged breaches of contract. Within (15) days after delivery of the notice, the
receiving pai�ty shall submit to the othet• a written response. The notice and the response shall
include (a) a statement of each party's position and a summary of arguments supporting that
position, and (b) the name aild title of the executive who will represent that party and of any
other person who will accompany the executive. Within (30) days a$er delivet�y of the disputing
party's notice, the eYecutives of both parties shall meet at a rnutually convenient time an place,
and thereafter as often as they r�easonably deem necessary, to attempt to resolve the dispute. All
reasonable requests for iliformation made by one party to the other will be honored. All
negotiations pursuant to this provision are confidential and shall be treated as compromise and
settlement negotiations fot• purposes of applicable rules of evidence. If the dispute is not resolved
by negotiation between executives, the parties sha11 endeavoi• to settle the dispute by mediation
undet• the then current CPR/AAA Mediation Procedure. Unless otherwise agreed, the parties will
select a mediator fi�oin CPR/AAA Panels ofMediators
Far� fur�ther inforrnation, see section titled "Dispute Resolution" of this Group Agreement, and the
section titled "Notice on Binding Arbitration" in the Evidence of Coverage (EOC).
ME HMO GA (Y2013) 2 GRP_12_178
The signatures below are evidence of Aetna's and Contract Holder's acceptance
of the Contract Holder's Group Application on the terms hereof and constitutes
execution of the Group Agreement(s) attached hereto on behalf of Aetna and
Contract Holder.
�
� ,
Signed this ����--- day of �` �� , 201�
AETNA HEALTH INC.
i�
�
Gregory S. Martino
Vice President
CONTRACT HOLDER:
� , �
�.:
� � I�.._:._ -
�'it PROVEU A T �ORi�i AND L�,rrALITY:
1
1 li �� X 1�...uc n 1V1 .,n n
:nx� �,tlY !fR[/f)11 �}� -- ;
-- _�_� - �._ _---- -,_ _-_ -,. -.. !
)'`� � (, � �" Z � $ "?. 2�
�
>
)
�� � /
��� � � � �
�a�,s�r, it3r' �ecret
/
B
�
;..-
q' �
�_
:�: ;
,.
.i
� ••c3A�W'+"
�,��� ����.
- �i . �
ME HMO GA (Y2013)
3
r ,�
_12_178
� , �:••- _ ��
AETNA HEALTH INC.
(TEXAS)
' � J' •- -'�'-- - ►/_I _ ►
This Group Agreement is entered into by and between Aetna Health Inc. and the Contract Holdet�
specified in the attached Cover Sheet. This Group Agreement shall be effective on the Effective
Date specified in the Cover Sheet, and shall continue in force until terminated as provided
herein.
In consideration of the mutual promises hereunder and the payment of Premiums and fees when
due, We will provide coverage for benefits in accordance with the ter•ms, conditions, limitations
and exclusions set forth in this Group Agr•eement.
Upon acceptance by Us of Contract Holder•'s Group Application, and upon receipt of the
requn•ed initial Premium, this Group Agreement shall be considered to be agreed to by Contract
Holder and Us, and is fully enfot•ceable in all respects against Contract Holder and Us.
SECTION 1. DEFINITIONS
1.1 "Aetna HMO Medicare plan" or "Plan" means Aetna Medicare Advantage HMO Plan,
including Medicare Prescription Drug benefits, offered to Contract Holder by Aetna
Health Inc. under this Group Agt�eement.
1.2 The terms "Aetna", "HMO", "Us", "We" or "Our" mean Aetna Health Inc., an affiliate ot�
a thir�d party vendor.
1.3 "CMS" means the Centers for Medicare and Medicaid Services.
1.4 The terms "Contract Holder", `Bffective Date", "Initial Term", "Premium Due Date" and
"Subsequent Terms" will ha�e the meaning set forth in the attached Cover Sheet. If any
of such terms are undefined in the Cover Sheet, such undefined terms shall have the
following meaning:
• "Effective Date" means the date health cover�age under this Group Agreeinent
comrnences for� the Contract Holder.
• "Initial Term" is the period following the Effective Date as indicated on the Cover
Sheet.
• "Pr•emium Due Date(s)" is the Effective Date and each tnonthly anniversary of the
Effective Date.
• "Subsequent Term(s)" means the per�iods following the Initial Term as indicated
on the Cover Sheet.
ME HMO GA (Y2013) 3 GRP_12_178
1.5 "Covered Benefits" is a general term we use to mean all of the health care setvices and
supplies including Medicare prescription drug benefits, that are covered by Our Plan,
subject to all ofthe terms and conditions ofthis EOC and this Group Agreement.
1.6 "EOC" means the Evidence of Coverage, which is a document outlining coverage for
Members under the Plan that is issued pursuant to this Group Agreement, and includes
the Schedule of Copayments and any riders or amendments.
1.7 "Grace Period" is defined in the Premiums and Fees section of this Group Agreement.
1.8 "Group Agreement" means the Contract Holder's Group Application, this document, the
attached Cover Sheet; the EOC and Schedule of Copayinents issued hereunder and
attached hereto as E�ibit A; the Rate Documents issued by Us in connection with this
Group Agreement and attached hereto as E�ibit B; the Plan Design and Benefit
Summary attached hereto as EYhibit C; and any riders, amendments, inserts or
attachments issued pursuant hereto, all of which are incorpor�ated into or incorporated by
reference into and made a part of this Group Agreement.
1.9 "Mandates" means applicable laws, regulations and other government requirements in
effect during the Term of this Group Agreement including, without limitation, applicable
Medicare laws, regulations and CMS requirements.
1.10 "Member" is a Medicare beneficiary who (1) has enrolled in Our Plan and whose
enrollment in the Plan has been confn�med by CMS, and (2) is eligible to receive
coverage under the Plan, subject to the terms and conditions of the EOC and this Group
Agreement.
1.11
1.12
"Party, Parties" means and Contract Holder.
"Premium(s)" is deiined in the Premiums and Fees section below.
1.13 "Renewal Date"
Subsequent Term.
means the first day following the end of the Initial Term or any
1.14 "Term" means the Initial Term or any Subsequent Term set forth in the Cover Sheet to
this Group Agreement.
1.15 Capitalized terms not defined in this Group Agreement shall have the meaning set forth
in the EOC. In the event of a conflict between the terms of this Group Agreement and
the terms ofthe EOC, the terms ofthis Group Agreement shall prevail.
2.1
SECTION 2. COVERAGE
Covered Benefits. We will provide coverage for Covered Benefits to Members subject
to the terms and conditions of this Group Agreement. Coverage will be provided in
accordance with the reasonable exercise of Our business judgment, consistent with
ME HMO GA (Y2013)
n
G�_12_17s
applicable law. Members covered undet• this Group Agreement are subject to all of the
conditions and provisions contained herein and in the incorporated documents.
2.2 Policies and Procedures. We have the right to adopt reasonable policies, procedut•es,
rules, and interpretations of this Group Agreement and the EOC in order to promote
orderly and efficient administration of the Plan and/or comply with Mandates ("Policies
and Procedures"). Aetna will provide Contract Holder with sixty (60) days advanced
written notice, unless a shorter period of time is t•equired for Aetna to comply with
Mandates, if Contract Holder must comply with any such Policies and Procedures.
SECTION 3. PREMIi1MS AND FEES
3.1 Premiums. Contract Holder shall pay Us on or before each Premium Due Date a
monthly pretnium (the "Premium") determined in accordance with the Premium rates and
the manner of calculating Premiums as set forth in Exhibit B. Premium rates and the
manner of calculating Premiums may be adjusted in accordance with the Membership
Adjustment section below. Pt•emiums are subject to adjustment, if any, for partial month
participation as specified in the Changes in Premium section below. Membership as of
each Premium Due Date will be determined by Us in accoydance with Our Member
records. A check does not constitute payment until it is honored by a bank. We may
t•eturn a check issued against insufficient funds without making a second deposit attempt.
We may accept a partial payment of Premium without waiving Our right to collect the
entu•e amount due.
This Group Agreement is subject to the annual renewal of the HMO's Medicare
Advantage Contract with CMS. Covered Benefits and/or Premiums are aiso subject to
change at the beginning of a Tet•m of this Group Agreement. Increases in Premiums
and/or decreases in Covered Benefits are only pet•mitted at the beginning of a Term of
this Group Agreement. Should CMS terminate Our contract as a Medicare Advantage
conh•actor or should We decide not to renew Our Medicare Advantage Contract,
Member•s shali be given notice of such termination in accordance with the HMO
Medicare Advantage EOC and any Mandates.
3.2 Fees. In addition to the Pretniutn, We may charge the following fees, if such fees are
agreed to in wt•iting by the parties:
• An installation fee may be charged upon initial installation of coverage or any
significant change in installation (e.g., a significant change in the nurnber of
Members or a change in the method of 1•eporting Membet� eligibility to Us). A fee
may also be charged upon initial installation for any custom plan set-ups.
• A billing fee may be added to each inontlily Premiurn bill. The billing fee may
include a fee for the recovety of any surcharges for atnounts paid through credit
card, debit card or• other similar means.
• A reinstaternent fee as set forth in the Effect of Termination section.
ME HMO GA (Y2013) 5 GRP_12_178
3.3 Past Due Premiums and Fees. If a Premiurn payment or any Fees are not paid in full by
Contract Holder on or before the Premium Due Date, a late payment charge in
accordance with Subchapter B of Chaptet• 2251 of the Government Code if all Premiums
and Fees are not received within 31 days following the Premium Due Date (the "Grace
Period"), Contract Holder's failure to make such payment will constitute a breach of this
Group Agreement and this Gt•oup Agreement will be automatically terminated pursuant
to the Termination by Us section het•eof.
If the Group Agreement terminates for any reason, Contract Holder will continue to be
held liable for all Premiums and Fees due and unpaid before the termination, including,
but not limited to, Premium payments for any period of time the Group Agreement is in
force during the Grace Period. Members shall also t•emain liable for Member cost
sharing and other required contributions to coverage for any period of time the Group
Agreement is in force during the Grace Period.
3.4 Chan�es in Premium. We may also adjust the Premium rates and/or the manner of
calculating Premiums upon prior written notice to Contract Holder, provided that such
prior written notice is provided as soon as reasonably possible, but no later than 120 days
prior to the effective date and no such adjustment will be made during the Initial Term
except as provided in the Rate Documents or to reflect changes in applicable law or
regulation or a judicial decision having a material impact on the cost of providing
Covered Benefits to Members.
3.5 Membership Adiustments. We may, at Our discretion, inake retroactive adjustments to
the Contract Holder's billings for the termination of Members not posted to previous
billings. However, Contract Holder may only receive a maximum of 2 calendar months
credit for Member terminations that occurred more than 30 days before the date Contract
Holder notified Us of the termination. We may t�educe any such credits by the amount of
any payments We may have made on behalf of such Members (including capitation
payments and other claim payments) before We were informed their coverage had been
terminated. Retroactive additions will be made at Our discretion based upon eligibility
guidelines, as set forth in the EOC, and are subject to the payment of all applicable
Premiums.
3.6 Uniform Premiums and Low Income Subsidv. Contract Holder shall comply with the
fo llowing conditions with respect to any subsidization of that portion of Premiums paid by
Contract Holder for the Medicare Prescription Drug benefit ("MA-PD Premium") and any
required MA-PD Pt•emium contribution by the Member:
• Contract Holder may subsidize different amounts of MA-PD Premium for
different classes of Members and their dependents, provided such classes are
reasonable and based on objective business criteria, such as years of service,
business location, job category, and nature of compensation (e.g., salaried vs.
hourly). Classes of Membeis and theu• dependents cannot be based on eligibility
for the Low Income Subsidy ("LIS") pt�ovided by CMS for certain individuals.
ME HMO GA (Y2013) 6 GRP_12 178
• MA-PD Pcemium contribution levels cannot valy for• Members within a given
class.
• Direct subsidy payinents fi•om CMS to Aetna tnust be passed through to reduce
the amount of any required MA-PD Premium payment by the Member ("Member
Contribution") so the Mernber in no event shall be requi��ed to pay more than the
sum of: a) the standard Medicare Par�t D premium, net of the dit•ect subsidy
payment from CMS, and b) one hundred percent (100%) for any supplernental
coverage selected by the Member.
Contt�act Holder shall comply with the following conditions with respect to any LIS
paytnent received from CMS for any LIS-eligible Member:
• Any monthly LIS payment received fi�om CMS for an LIS-eligible Member shall
be used to reduce any Member Conh•ibution. Any remainder may then be used to
reduce the amount of the Contract Holder's MA-PD Premium contribution.
• If the LIS payment for any LIS-eligible Member is less than the Member
Contribution requi�•ed by such individual (including the Member Contribution for
supplemental benefits, if any), Contract Holder shall cotnmunicate with the LIS-
eligible Member about the cost of remaining enrolled in Contract Holder's plan
versus obtaining coverage as an individual under another Medicare Part D
Prescription Drug plan.
SECTION 4. ENROLLMENT
4.1 Open Enrollment. Contract Holder will offer enrollment in the Aetna Medicare HMO
plan:
• at least once during the term of this Group Agreement during Contract Holder's
annual open enrollment period ("Open Enrollment Period"); and
• within 31 days fi•om the date an individual or any dependent becomes eligible to
receive covet�age under the Plan.
Eligible individuals and dependents who are not enrolled in the Plan within the Open
Enrollment Period or 31 days of becoming eligible may be enrolled during any
subsequent Open Em•ollrnent Period. Coverage under the Plan will not become effective
until confirmed by Us. Contract Holdet• agi•ees to hold the Open Ent•ollment Period
consistent with the open enrollment period applicable to any other group health benefit
pian being offered by the Contract Hoider and in compliance with Mandates. The
Contract Holder shall permit Our representatives to meet with eligible individuals and
dependents during the Open Enrollment Period unless the parties agree upon an alternate
enrollment procedure.
4.2 Waiting Period. Contract Holder may irnpose a waiting period before individuals are
eligible for coverage under this Gi•oup Agreernent.
ME HMO GA (Y2013) 7 GRP 12 178
4.3 Eli�ibilitv. Active employees and their dependents are not permitted to enroll in the
Plan, unless Contract Holder employs between two and nineteen (2-19) employees. The
number of eligible individuals and eligible dependents and composition of the group, the
identity and status of the Contract Holder, the eligibility requirements used to determine
membership in the group, and the participation and contribution standards applicable to
the group which exist at the Effective Date of this Group Agreement are materiai to the
execution and continuation of this Group Agreernent by Us. The Contract Holder shall
not, during the Term of this Group Agreement, modify the Open Eru�ollment Period or
any other eligibility requirements as described in the EOC and on the Schedule of
Copayments, for the purposes of enrolling Contract Holder's eligible individuals and
eligible dependents under this Group Agreement, unless We agree to the modification in
writing.
SECTION 5. RESPONSIBILITIES OF THE CONTRACT HOLDER
In addition to other obligations set forth in this Group Agreement, Contract Holder agrees to:
5.1 (A) Records. Furnish to Us, on a monthly basis (or as otherwise required), on Our form
(or such other form as We may reasonably approve) by facsimile (or such other means as
We may reasonably approve), such information as We may reasonably require to
administer this Group Agreement. This includes, but is not limited to, information
needed to enroll members of the Contract Holder, process terminations, and effect
changes in family status and transfer of employment of Membeis.
Contract Holder certifies, based on best knowledge, information and belief, that all
enrollment and eligibility information that has been or will be supplied to Us is accurate,
complete and truthful. Contract Holder acknowledges that We can and will rely on such
enroliment and eligibility information in determining whether an individual is eligible for
Covered Benefits under this Group Agreement. To the extent such information is
supplied to Us by Contract Holdet� (in electronic or hard copy format), Contract Holder
agrees to:
• Obtain fi•om all Members a"Disclosure of Healthcare Information" authorization
in the form currently being used by Us in the enrollment process (or such other
form as We may reasonably approve).
• Maintain a reasonably complete record of such information (in electronic or hard
copy format, including evidence of coverage elections, evidence of eligibility,
changes to such elections and terminations) for at least ten (10) years and to make
such information available to Us upon request, as required under this Section 5.
We will not be liable to Members for the fulfillment of any obligation prior
information being received in a form satisfactory to Us. Contract Holder must notify
of the date in which a Member's employment/eligibility ceases for the purpose
tet•mination of coverage under this Group Agreement.
ME HMO GA (Y2013)
F:
to
Us
of
GRP_12_178
(B) Maintenance of Information ancl Recorcls. Contract Holdei• agrees to maintain
Information and Records (as those terms defined in the Access to Information and
Records section below) in a current, detailed, organized and comprehensive manner and
in accordance with Mandates, and to maintain such Information and Records for the
longer of: (i) a period of ten (10) years from the end of the final contract period of any
govet�nment contract of Aetna to offer an Aetna Medicare HMO plan, (ii) the date the
U.S. Depat�tinent of Health and Human Services, the Comptroller General or theit�
designees complete an audit, or (iii) the period required by Mandates. This Provision
shall sutvive the termination of this Group Agreement, regardless of the cause of the
termination.
(C) Access to Information and Records. Contract Holder agrees to provide Us and
federal, state and local governmental authorities having jurisdiction, directly or through
theu• designated agents (collectively "Government Officials"), upon request, access to all
books, records and other papers, documents, materials and other information (including,
but not limited to, contracts and financial records), whether in paper ot• electronic format,
relating to the arrangement described in this Grou}� Agreement (`Information and
Records"). Contract Holder agrees to provide Aetna and Govet•nment Officials with
access to Information and Records for as long as it is maintained as provided in the
"Information and Records" section above. Contract Holder agrees to supply copies of
Information and Records within fourteen (14) calendar days of Contract Holder's receipt
of the request, where practicable, and in no event later than the date required by an
applicable law or regulatoly authority. This provision shall sutvive termination of this
Group Agreement, regardless of the cause of termination.
5.2 Forms. Distribute materials to Members regarding enrollment, health plan features,
including Covered Benefits and exclusions and limitations of coverage. Contract Holder
shall, within no fewer than 10 days of receipt from an eligible individual, forward all
completed enrollment information and other required information to Us.
5.3 Policies and Procedures: Compliance Verification. Comply with all policies and
pt�ocedures established by Us in administering and interpreting this Group Agreement.
Aetna will notify Contract Holder of any policies and procedures that Contract Holder is
requu•ed to comply with under this Section 5.3. Aetna will pr•ovide Contract Holder with
sixty (60) days advanced written notice, unless a shorter period of time is requu•ed for
Aetna to comply with Mandates, if Contract Holder must comply with any such Policies
and Procedures. Contt�act Holder shall, upon request, provide a cet�tification of its
compliance with Our participation and contribution requirements and the requit�ements
for a group as defined under Mandates.
5.4 Written Notice to Members. Contract Holder shall distr�ibute to Members any written
notice that We provide to Contt•act Holder for distribution to Metnbers (including, but not
limited to, the Annual Notice of Change (ANOC) and any other written notice required
under Mandates) within the timeframe indicated by Us. Contract Holder� will provide
Members with written notice describing any changes rnade to Covered Benefits at least
thit�ty (30) days prior to the effective date of such change(s) or as required under
ME HMO GA (Y2013) 9 GRP 12 178
Mandates. Contract Holder will provide Members with any written notice required under
Mandates or policies and procedures established by Us in administering and inteipreting
this Group Agreement. The written notices described in this section are hereinafter
collectively refer�t•ed to as the "Written Notices". If Contract Holder does not distribute
Written Notices to Members as required under this section 5.4, Contract Holder will be
liable to the extent allowed by law for payment of all Premiums or other costs incurred by
Us as a result of Contract Holder's failut�e to distribute the Written Notices. If Contract
Holder does not distribute the Written Notices as requu�ed under this section, We may, in
our discretion, distribute such Written Notices to Members, and Contract Holder shall
r�eimburse Us to the extent allowed by law for any expenses incurred by Us in connection
with such distribution.
CMS requu•es that all Members receive from Aetna a combined ANOC and EOC no later
than the sooner of (1) fifteen (IS) days prior to the Open Enrollment Period, (2)
September 30th of each calendar yeat•, or (3) such shorter timeframe required under
Mandates.
5.5 Member Plan Materials. Contract Holder shall assure that any Member Plan materials
that have not been approved by CMS comply with the following alternative disclosure
standards: the Employee Retirement Income Security Act of 1974, as amended
("ERISA") or any alternative disclosure standards applicable to state or local entities that
provide employee/retu�ee benefits.
5.6 FRISA Requirements. Maintain res�on:sibility for makin� i•�pot•ts and dis�lc�s��r�s
requi��ed by the Employee Retirement Income Security Act of 1974, as amended
("ERISA"), including the creation, distribution and final content of summary plan
descriptions, summary of material modifications and summaiy annual reports, unless
Contract Holder's Plan is specifically exempt thereunder.
5.7 Enrollment & Disenrollment Transactions.
(A) Generallv. To the extent that Contract Holder di�•ectly accepts enrollment and/or
disenrollment requests from Members that Contract Holder forwards to Aetna for
processing and submission to CMS, Contract Holder agrees to comply with all Mandates
that relate to the handling and processing of enrollment and disenrollment requests that
apply to the Plan ("Enrollment/Disenrollment Requirements"), including, without
limitation, all Enrollment/Disenrollment Requu�ements that relate to the timeframes that
apply to handling, pt•ocessing and submission of eru•ollment and disem�ollment requests
for the Plan. Contract Holder agrees to forwar•d enrollment and disenrollment forms
completed by Members to Aetna no later than ninety (90) days after the Member's
coverage effective date. Contract Holder acknowledges that if there is a delay between
the time a Member submits an enrollment/disenrollment request to Contract Holder and
when the enrollment/disem•ollment request is received by Aetna, the
enrollment/disenl•ollment transaction may not be processed by CMS, tmless Aetna
requests and CMS approves a retroactive enrollment/disenrollment transaction for the
Member. Contract Holder further acknowledges that Aetna, in its sole discretion and
judgment, will determine whether to submit t•etroactive enrollment and disenrollment
ME HMO GA (Y2013)
10
GRP_12_178
transaction requests to CMS, and will make such determinations in accot�dance with
Mandates.
Contract Holder acknowledges that, per Eruolhnent/Disenrollment Requirements, the
effective date of enrollments and disenrollments in the Plan cannot be earlier than the
date the enrollment or disenrollment request was completed by a Member. If approved by
CMS, the effective date of an enrollment or disenrollment may be retroactive up to, but
may not exceed, ninety (90) days frorn the date that Aetna received the enrollment or
disenrollment request from Contract Holder, and the enrollment or disenrollment form
must be completed and signed by the Member prior to the requested enrollment or
disenrollment effective date.
Contract Holder acknowledges that CMS does not permit Contract Holder to
retroactively terminate a Member's coverage under the Plan if the Member no longer
meets Contract Holder's eligibility criteria to remain enrolled in the Plan. To meet these
CMS requirements, Contract Holder agrees to provide Aetna with wr•itten notice if
Contract Holder chooses to terminate a Member's coverage under• the Plan based on loss
of eligibility, and Contract Holder acknowledges that the Member's coverage termination
effective date wi11 be determined in accordance with Mandates.
All of the requireinents described in this Section 5.7 also apply equally to any third party
administrator or other entity retained by Contract Holder to accept and/or pt•ocess
enrollmenddisenrollment requests for the Plan from Members on Contract Holder's
behalf.
(B) Notice to Members. CMS requires that Aetna provide written notice to all Members
confirming their enrollment in or disenrollment from the Plan from Aetna. The written
notice confirming a Mernber's disent•ollment fi�om the Plan that is sent by Aetna must
describe how the Metnber can contact Medicare for information about other Medicare
Advantage or Medicare Prescription Drug plan options that may be a�ailable to the
Member.
If Contract Holder elects to change the health plan coverage offered to Members by
Aetna or tet•minate the Member's coverage undet• the Aetna Medicare Advantage HMO
Plan, the Contract Holder must provide written notice to the Member at least twenty-one
(21) calendar days prior to the effective date ofthe change in the Member's cover�age or
disenrolltnent fi•om the Aetna Medicare Advantage HMO Plan, as applicable.
We reserve the i•ight to notify Members of the involuntat�y termination of their coverage
under the Group Agreement for any reason.
(C) Electronic Enrollment and Diseurollment. To the extent that the Contract Holdei•
has elected to electronically enroll eligible employees or retit•ees and theit• eligible
dependents ("Eligible Party" or Eligible Parties") in the Aetna Medicare HMO plan
("Enroll" ar� `Bm�ollment") and to electronically terminate the coverage
under the Aetna Medicare HMO pian ("Disenroll" or "Disenrollment"),
of Melnbers
and Aetna has
ME HMO GA (Y2013) 11 GRP_12_178
agreed to accept Enrollment and Disenrollment information fi•om Contract Holder
through a roster and electronically process such Enrollments and Disenrollments,
Contr�act Holder must meet certain administrative and legal t•equn•ements set forth in this
section of this Group Agreement.
Aetna will electronically Enroll Eligible Parties who have elected the Aetna Medicare
HMO plan covet•age ("Electronic Enrollment") and electronically Disenroll Members
fi•om the Aetna Medicare HMO plan ("Electronic Disenrollment"), provided Contract
Holder meets the following requi�•ements:
• Uses Aetna enrollment and Disenrollment forms approved by CMS for Electronic
Enrollments and Disenrollments ("Aetna Enrollment and Disenrollment Farms").
As pei7nitted under Mandates and this Group Agreement, Contract Holder may
permit Eligible Parties to electronically submit an election form to enroll in an
Aetna Medicare Plan ("Online Enrollment Form") to Contract Holder ("Online
Election Process").
• Confirms that all Aetna Enrollment and Disenrollrnent Forms and Online
Enrollment Forms contain all data required by CMS, prior to requesting that
Aetna process any Electronic Enrollments or Disenrollments.
• Maintains and provides access to all original Aetna Em•ollment and Disent•ollment
Forms and Online Ern�ollment Forms completed by Eligible Parties and Members
in accordance with the Records section of this Group Agreement and all
Mandates.
• Submits Electronic Enrollment and Disenrollments to Aetna timely and accurately
in accordance with Mandates, Aetna policies and procedures, and this Group
Agreement.
• Submits to Aetna all data elements that are requn•ed by CMS and Aetna with
respect to each Electt�onic Enrollment and Disenrollment, including, but not
limited to, the following data eletnents:
• Name
• Permanent Address
• Medicare Claim Number (HICN)
• Gender
• Date of Birth
• Plan Selection
• Providet� Selection (if applicable)
• Gr•oup Number
• Class Code
• Plan ID
• Effective Date
Contract Holder agrees to be bound by all Mandates applicable relating to Electronic
Enrollment and Disenrollment. If Aetna determines, in its sole discretion and judgeinent,
ME HMO GA (Y2013)
12
GRP_12_178
that the Electronic Enrollment or Disenrollment infot•mation provided by Contract Holder
is incotnplete, the Electronic Enrollment or Disenrollment will not be processed.
Electronic Enrollments deemed by Aetna to be complete will be processed by Aetna for
the first of the month following receipt of the electronic file from Contract Holder.
Electronic Enrollments may be processed 90 days retroactively from the current CMS
effective cycle date when the following conditions apply:
• The t�equested effective date is indicated on the Aetna Em�ollment Form or Online
Enrollment Form completed by an Eligible Party, and on the electronic file
transmitted by Contract Holder to Aetna; and
• The Aetna Enrollment Form is signed or the Online Enrollment Form is received
by an Eligible Party prior to the requested effective date or prior to the date the
Aetna Enrollment Form or Online Enrolltnent Form was completed by the
Eligible Parry.
Electronic Disenrollments deemed by Aetna to be complete will be processed by Aetna
for the first of the month following receipt of the electronic file. Aetna will only process
Electronic Disenrollments where an Eligible Party has voluntarily elected to Disenroll
fi•om an Aetna Medicat�e HMO Plan by subrnitting a fully completed Aetna
Disent•oliment Form to Contract Holder. Aetna will not process Electronic
Disenrollments where Contract Holder has elected to Disenroll an Eligible Parry fi•om an
Aetna Medicare HMO Plan due to Eligible Party's failure to pay Plan premium or any
other basis.
Contract Holder will produce, at Aetna's request, the original copy of any Aetna
Enrollment or Disenrollment Form or record of the Online Enrollment Form completed
by an Eligible Party.
Contract Holder agrees that it will transmit to Aetna only that information which is
t�eflected on an Aetna Enrollment or Disenrollment Form or Online Enrollment Form that
is completed and signed, as required, by an Eligible Party.
Contract Holder agrees to obtain fi•om Eligible Parties information, including
authorizations, reasonably necessaty for Aetna to perform its obligations under the
arrangements set forth in this Group Agreement.
Aetna shall not be responsible for any costs, expenses, claims or judgments, including
attorney's fees resulting from Contract Holder's failure to comply with the terms of this
provision.
SECTION 6. TERMINATION
6.1 Termination bv Contract Holder. This Group Agreement rnay be tertninated by
Contract Holder by providing Us with 60 days prior written notice ("Notice of
Termination"). The Notice of Terrnination shall specify the effective date of such
ME HMO GA (Y2013) 13 GRP_12_178
termination, which shall be on the 1 St day of a calendar month and may not be less than
60 days from the date of the notice, and including the following information: Contract
Holder's name, Conh•act Holder's Group Number, Service Area(s) (if Contract Holder
elects to terminate the Plan in soine, but not all, Service Areas covered under this Group
Agreement), Plan name, and the effective date of termination of the Gr•oup Agreement.
6.2 Renewal of GrouU A�reement. This Group Agreement is i•enewable annually, unless
Aetna will no longer offet• any Medicare Advantage HMO plan in any Service Areas
covered under this Group Agreement because: (1) CMS terminates or otherwise non-
renews the HMO's Medicare Advantage contract with CMS, or (2) We terminate Our
Medicare Advantage Contract or reduce the service areas referenced in its Medicare
Advantage Contract with CMS.
6.3 Termination bv Us. This Group Agreement will terminate as of the last day of the
Grace Period if the Premium remains unpaid at the end of the Grace Period.
This Group Agreement may also be tertninated by Us as follows:
• Immediately upon notice to Contract Holder if Contract Holder has performed
any act or practice that constitutes fraud or made any intentional
misrepresentation of a material fact relevant to the coverage provided under this
Group Agreement;
• Immediately upon notice to Contr•act Holder if Contract Holder no longer has any
enrollee under the Plan who resides in the Service Area;
• Upon 30 days written notice to Contract Holder if Contract Holder (i) breaches a
provision ofthis Gr�oup Agreement and such breach remains uncured at the end of
the notice period; (ii) ceases to meet Our requu•ements for an employer group or
association; (iii) fails to meet Our contribution or participation requirements
applicable to this Group Agreement (which contribution and pat•ticipation
requirements are available upon request); (iv) fails to provide the certification
required by the Policies and Procedures; Compliance Verification section within
fourteen (14) business days of Our request, unless a shorter period of time is
required for Aetna to comply with Mandates; (v) provides written notice to
Members stating that coverage under this Group Agreement will no longer be
provided to Members; (vi) changes its eligibility or participation requirements
without Our consent or (vii) ceases to meet any Mandates applicable to offering
the Plan to Contract Holder;
• Upon 180 days written notice to Contract Holder (ot� such shortet� notice as may
be permitted by applicable law, but in no event less than 30 days) if We cease to
offer a product or coverage in any inarket in which Members covered under this
Group Agreement reside;
ME HMO GA (Y2013)
14 GRP_12_178
• Upon 30 days written notice to Contract Holder for any other reason which is
acceptable to CMS and consistent with the Health Insurance Portability and
Accountability Act of 1996 ("HIPAA") or other Mandates; or
• Immediately upon notice to Contt�act Holder if Contract Holder is a member of an
employer-based association group, the Contract Holder's membership in the
employer-based association ceases.
6.4 Effect of Termination. No termination ofthis Group Agt•eement will relieve either party
from any obligation incurred before the date of termination. When terminated, this
Group Agreement and all coverage provided hereunder will end at 12:00 midnight on the
effective date of termination. We may charge the Contract Holder a reinstatement fee if
coverage is terminated and subsequently reinstated under this Group Agreement.
6.5 Notice to Members. It is the responsibility of Contract Holder to notify Metnbers of the
termination of the Group Agreement in compliance with all Mandates and Our policies
and procedures. However, We reserve the right to notify Members oftermination ofthe
Group Agreement for any reason, including non-payment of Premium. In accordance
with the EOC and applicable CMS requit�ements, Contract Holder shall provide written
notice to Members of their rights upon termination of coverage.
SECTION 7. PRIVACY OF INFORMATION
7.1 Compliance with Privacv Laws. We and Contract Holder will abide by all Mandates
regarding confidentiality of individually ideniifiable health and other personal
information, including the privacy requirements of HIPAA.
7.2 Disclosure of Protected Health Information. We will not provide protected health
itiformation ("PHI"), as defined in HIPAA, to Contract Holder, and Contract Holder will
not request PHI from Us, unless Contract Holder• has:
• provided the certification requit�ed by 45 C.F.R. � 164.504(fl and amended
Contract Holdei•'s Plan documents to incorpot•ate the necessary changes requit�ed
by such rule.
7.3 Brokers and Consultants. To the eYtent any broket• or consultant receives PHI in the
underwriting pt�ocess or while advocating on behalf of a Metnber, Contt�act Holder
undet•stands and agrees that such broker or consultant is acting on behalf of Contract
Holder and not Us. We are entitled to rely on Contract Holder's t•epresentations that any
such broker or• consultant is authorized to act on Contt�act Holder's behalf and entitled to
have access to the PHI under the relevant circumstances.
ME HMO GA (Y2013) 15 GRP 12 178
SECTION 8. INDEPENDENT CONTRACTOR RELATIONSHIPS
INDEMNIFICATION
8.1 Relationship Between Us and Network Providers. The t�elationship between Us and
Network Providers is a contractual relationship among independent contractors. Network
Providets are not agents or employees of Us nor are We an agent or� employee of any
Network Provider.
Network Providers are solely responsible for any health services rendered to Members.
We make no express or implied warranties or t�epresentations concerning the
qualifications, continued participation, or quality of services of any Network Provider. A
provider's participation in the provider network for the Plan may be terminated at any
time without advance notice to the Contract Holder or Members, subject to applicable
law. Network Providers provide health care diagnosis, treatment and services for
Members. We administer and detet•mine Plan benefits.
8.2 Relationship Between the Parties. The relationship between the Parties is a contractual
relationship between independent contractors. Neither Party is an agent or employee of
the other in performing its obligations puisuant to this Group Agreement.
8.3 Indemniiication. Generally, ERISA preempts all non-insurance state laws insofar as
they relate to an employee benefit plan covered by ERISA. In the event this plan meets
the definition of an ERISA Plan pursuant to Section 3(3) of ERISA, there should be no
liability by Us or Contract Holder to third parties pursuant to state law that arises out of
this Group Agreement, Our performance hereunder, or Contract Holder's role as
employer or Plan Sponsor. Nevertheless, in order to fully define indemnity obligations
(a) in light of the possibility of a change in law affecting ERISA preemption of state law
and (b) in the case of an action under ERISA, the parties agree to the following:
• We shall indemnify and hold harmless Contract Holder for• that portion of any
liability, settlement and related expense (including the cost of legal defense)
which was caused by Aetna, du•ectly and independently of all other causes by Our
fraud, willful misconduct, criminal misconduct, negligence, gross negligence, or
material bt•each of this Group Agreement.
• Contract Holder shall indemnify and hold harmless Us, Our affiliates and their
respective directors, officers, eligible individuals or agents, to the extent required
by law for that portion of any liability, settlement and related expense (including
the cost of legal defense) which was caused by Contract Holder's negligence,
breach of this Group Agreement, breach of applicable Mandates, willful
misconduct, critninal conduct, fi•aud, or its breach of fiduciary responsibility in
the case of an action under applicable Texas law, related to or arising out of this
Group Agreement.
ME HMO GA (Y2013) 16 GRP_12_178
The party seeking indetnnification under the first or second bullet above must notify the
indernnifying party within fifteen (15) business days in writing of any actual or
threatened action, suit or proceeding to which it claims such indemnity applies. Failure
to so notify the indemnifying party shall be deemed a waiver of the right to seek
indemnification to the extent permitted by law.
The Parties agree that neithei• is r�esponsible for patient care and related treatment
decisions which are the sole responsibility of Providers, that Providers are not the agents
of either, and that in no event shall the indemnity obligations under the first or second
bullet above apply to that portion of any liability, settlement and related expense caused
by the acts or omissions of Providers with respect to Members.
The Parties agree that in no event shall the indemnity obligations undei• the first or second
bullet above apply to that portion of any liability, settlement and related expense caused
by (a) Our act or omission undertaken at the eYpress written dii•ection of Contract Holder
or Contract Holder's agent; or (b) Contract Holder's act or omission undertaken at Our
expressed written direction.
The indemnification obligations of the Parties shall terminate upon the expiration of this
contract except as to any matter concerning a claim which has been asserted by notice to
the other Party on or before the statute of limitations period applicable to such claitn.
SECTION 9. MISCELLANEOUS
9.1 Dele�ation and Subcoutractin�. Contract Holder acknowledges and agrees that We
may enter into arrangements with third pat•ties to delegate functions hereunder such as
utilization management, quality assurance and provider credentialing, as We deem
appropriate in Our sole discretion and as consistent with Mandates. Contract Holder also
acknowledges that Out• arrangements with thit�d party vendors (i.e. pharmacy, behavioral
health) are subject to change in accordance with Mandates.
9.2 Accreditation and pualiiication Status. We tnay fi�om tune to time obtain voluntary
accreditation or qualification status from a pt�ivate accreditation organization ot•
govet�nment agency. We make no express or iinplied warranty about Our continued
qualification ot� accreditation status.
9.3 Prior A�reements; Severabilitv. As of the Effective Date, this Group Agreernent
replaces and su�ersedes all other prior agreements between the Parties as well as any
other prior written or oral understandings, negotiations, discussions or arrangements
between the Parties related to the coverage(s) addressed by this Group Agreetnent or the
documents incorporated hei•ein. If any pr•ovision of this Group Agreetnent is deetned to
be invalid o�� illegal, that provision shall be fully severable and the remaining provisions
of this Group Agreement shall continue in full force and effect.
9.4 Amendments. This Gr�oup Agreeinent may be amended as follows:
ME HMO GA (Y2013) 17 GRP 12 178
• This Group Agreement shall be deemed to be automatically amended to conform
with ali Mandates promulgated at any time by any state or federal regulatory
agency or authority having supervisoiy authority over Us;
• By written agreement between both Parties.
The Pat•ties agree that an amendment does not require the consent of any Member or
other person. Except for automatic amendments to comply with law, all amendments to
this Gt•oup Agreement must be approved and executed by both parties. No other
individual has the authority to modify this Group Agreement; waive any of its provisions,
conditions, or restrictions; extend the time for making a payment; or bind Us by making
any other commitment or r•epresentation ot• by giving ar receiving any information.
9.5 Clerical Errors. Clerical errors or delays by Us in keeping or reporting data relative to
coverage will not reduce or invalidate a Member's coverage. Upon discovet•y of an error
or delay, an adjustment of Premiums shall be made. We may also modify or replace a
Group Agreement, EOC or other docutnent issued in error.
9.6 Claim Determinations and Administration of Covered Benefits. We have complete
authority to review all claims for Covered Benefits as defined in the EOC under this
Group Agreement. In exercising such responsibility, We shall have discretionary
authority to reasonably determine whether and to what extent eligible individuals and
beneficiaries are entitied to coverage and to construe any disputed or doubtful terms
under this Group Agreement, the EOC or any other document incorporated herein. We
shall be deemed to have properly exercised such authority unless We abuse Our
discretion by acting arbitrarily and capriciously. Our review of claims may include the
use of commercial software (including Claim Check) and other tools to take into account
factors such as an individual's claims histot•y, a provider's billing patterns, complexity of
the service or treatment, amount of time and degree of skill needed and the manner of
billing. The administration of Covered Benefits and of any appeals filed by Members
related to the processing of claims for Covered Benefits shall be conducted in accordance
with the EOC and any Mandates.
9.7 Misstateinents. If any fact as to the Contract Holder or a Member is found to have been
misstated, an equitable adjustment of Premiums may be made. If the misstatement
affects the existence or amount of coverage, the true facts will be used in determining
whether coverage is or remains in force and its amount.
9.8 Incontestabilitv. Except as to a fraudulent misstatement, or issues concerning Premiums
due:
• No statement made by Contract Holder or any Member shall be the basis for
voiding coverage oi• denying coverage or be used in defense of a claim unless it is
in writing.
• No statement made by Contt�act Holder shall be the basis for voiding this Group
Agreement after it has been in force for two years from its effective date.
ME HMO GA (Y2013)
E
GRP_12_178
9.9 Waiver. Failure to implement, ot� insist upon compliance with, any provision of this
Group Agreement or the ter�ms of the EOC incorporated hereunder, at any given time or
times, shall tlot constitute a waiver of right to implement or insist upon compliance with
that provision at any other time or times. This includes, but is not limited to, the payment
of Premiums or benefits. This applies whether or not the circumstances are the satne.
9.10 Notices. Any notice required or pet�mitted undet� this Group Agreement shall be in
writing and shall be deemed to have been given on the date when delivered in person; or,
if delivered by fu•st-class United States mail, on the date mailed, proper postage prepaid,
and properly addressed to the address set forth in the Group Application or Cover Sheet,
or to any more recent address of which the sending party has received written notice ot�, if
delivered by facsimile or other electronic means, on the date sent by facsimile or other
electronic means.
9.11
9.12
Third Parties. This Group Agreetnent shall not confer any rights or obligations on third
parties except as specifically provided herein.
Non-Discrimination. Contract Holder agrees to make no attempt, whether thr•ough
differential contributions or otherwise, to encourage or discourage em�oliment in the
Aetna Medicare HMO Plan of eligible individuals and eligible dependents based on
health status or health risk.
9.13 Compliance with Law. Aetna and Contract Holder shall comply with all Mandates
applicable to the performance of their respective obligations under this Group
Agreement.
9.14 Applicable Law. This Group Agreement shall be governed and consttued in accordance
with applicable federal law and the applicable law, if any, of the state specified in the
Cover Sheet or, if no state law is specified, Our domicile state.
9.15 Inabilitv to Arrau�e Services. If due to circumstances not within Out� reasonable
control, including but not limited to rnajor disaster, epidemic, complete or partial
destruction of facilities, riot, civil insurrection, disability of a significant part of Our
Network Pr•oviders or entities with whom We have contracted for services under� this
Gt�oup Agreement, or similar causes, the provision of inedical or hospital benefits or
other setvices provided under this Group Agreement is delayed or rendered impractical,
We shall not have any liability or obligation on account of such delay or failure to
pr�ovide services, except to refund the amount of the unearned prepaid Premiums held by
Us on the date such event occurs. We are required only to make a good-faith effort to
provide or arrange for the provision of setvices, taking into account the impact of the
event.
9.16
Use of the Aetna Name and all Svmbols, Trademarks, and Service Marks. We
reserve the right to control the use of Our name and all symbols, trademarks, and service
ME HMO GA (Y2013) 19 GRP 12 178
9.17
marks presently existing or subsequently established. Contract Holder agrees that it will
not use such name, symbols, trademarks, or service marks in advertising, promotional
materials or similar materials which describe the plan without Our prior• written consent
and will cease any and all usage immediately upon Our request or upon termination of
this Group Agreement.
Disqute Resolution.
Any Claim alleging wrongful acts or omissions of Network Providet• or a provider that
does not participate in the pi�ovider network for the Plan ("Non-Network Providers") shall
not include Us. Contract Holder may not recover any damages arising out of or related to
the failure to approve or provide any benefit or coverage beyond payment of or• coverage
for the benefit or coverage where (i) We have made available independent external
review and (ii) We have followed the reviewer's decision.
9.1 S Workers' Compensation. In accordance with 42 C.F.R. Section 422.108, as may be
amended fi•om time to time, and othef• Mandates, Contract Holder is t•esponsible for
protecting Our interests in any Workers' Compensation claims or settlements with any
Member. We shall be reimbursed for all paid medical expenses which have occurred as a
result of any work related injury that is compensable or settled in any manner.
Upon Our request, Contract Holder shall also submit a monthly report to Us listing all
Workers' Compensation cases for• Members who have outstanding Workers
Compensation claims involving the Contract Holder. Such list will contain the name,
social security number, date of loss and diagnosis of all applicable Members.
9.19 Medicare Secondary Paver Requirements.
• Generally. Aetna and Contract Holder agree to comply with
Secondaly Payer ("MSP") Mandates that apply to Contract Holder,
Aetna ("MSP Requirements").
all Medicare
the Plan and
• MSP Requu•ements Applicable to Medicare Beneficiaries Diagnosed with End
Stage Renal Disease (ESRD). Aetna and Contract Holder agree to comply with
all MSP Requi�•ements appiicable to Contract Holder's active employees and
retit•ees and their dependents who are Medicare beneficiaries diagnosed with
ESRD ("ESRD Beneficiaries" or "ESRD Beneficiary"), including, without
limitation, those MSP Requirements set forth in 42 U.S.C. § 1395y(b)(1)(C), 42
C.F.R. §§ 411.102(a), 4ll.161, and 4ll.162 and 42 C.F.R. §§ 422.106 and
422.108 ("ESRD MSP Requirements").
• Contract Holder acknowledges and agrees that if an ESRD Beneficiaiy is eligible
for or entitled to Medicare based on ESRD, the MSP Requirements requu•e the
commercial group health plan offered by Contract Holder ("GHP") to be the
primary payer for the iit�st thi�•ty (30) months of the ESRD Beneficiary's Medicare
eligibility or entitlement ("30-month coordination period"), regardless of the
ME HMO GA (Y2013)
/71]
GRP_12_178
number of employees employed by Contract Holder and regardless of whether the
ESRD Beneficiary is a curt�ent employee or retiree.
• In furtherance of Aetna's and Contract Holder's compliance with ESRD MSP
Requirements, Contract Holder agrees to confirm to Aetna whether ESRD
Beneficiar•ies are in their 30-month coordination period, and not seek to enroll
ESRD Beneficiaries in the Plan during thei�• 30-month coordination pet�iod unless
coverage under the GHP is maintained for such ESRD Beneficiaries for that
period. If Contract Holder seeks to enroll an ESRD Beneficiary in the Plan,
Contt�act Holder agrees to provide Aetna, upon request, with infor•mation or
documentation to verify compliance with ESRD MSP Requirements, including
any MSP reporting or other requirements established by CMS.
9.20 Order of Prioriiv. In the event of any conflict between the terms and conditions of the
Financial Conditions and those of the Group Agreement between Contract Holder and Aetna, the
terms and conditions of the Group Agreement will contr•ol.
ME HMO GA (Y2013) 21 GRP 12 178
Exhibit B: MEDICARE ADVANTAGE RATE
PROPOSAL
Plan Sponsor
Name:
Plan Sponsor Number:
Policy Period Start Date:
Policy Period End Date:
Medical Plan:
Dental Plan:
Hearing Hardware:
Lens
Reimbursement:
City of Fort
Worth
Unassigned
01 /01 /2013
12/31/2013
HMO 100%
Plan
Not Covered
$2,000 / 36
months
Vision 200
♦ Please refer to the Financial Conditions and Plan Design Exhibits for an outline of
the level of benefits quoted, as well as the terms and conditions of this proposal.
e All rates are on a Per Member Per Month (PMPM) basis.
o Filed benefits (including copayment amounts), value added services and
premiums are subject to CMS approval, and are effective January 1, 2013
through December 31, 2013.
All counties are included where Aetna Medicare is available.
These plans are being ofFered on a national rate basis.
New 25% 50% 75°/a 100%
Assumed Enrollment 100 430 725 1,020 1,181
Total Medical Rates $157.21 $157.21 $157.21 $157.21 $157.21
Geo Medicare
State Rating Counties Eligible Medical Rate
Area Members
Arizona 452 Maricopa 1 $157.21
Lake, Orange, 1 $157.21
Florida 1055 Seminole
Hillsborough, Lee,
Manatee, Pasco, 2 $15721
Pinellas, Polk,
Florida 1058 Sarasota
ME HMO GA (Y2013) 22 GRP_12 178
Florida 1069 Miami-Dade 1 $157.21
Geor ia 1152 Cobb, Fors th 1 $157.21
Clayton, Fulton,
Gwinnett, Henry, 2 $157.21
Geor ia 1153 Paulding, Spaldin
Cook, DuPage, 1 $157.21
Illinois 1551 Lake, WII
Kansas 1751 Johnson 1 $157.21
Missouri 2555 Jefferson 1 $157.21
Gaston, 2 $157.21
North Carolina 2853 Mecklenbur
Ohio 3651 Lorain, Richland 1 $157.21
Butler, Clermont,
Hamilton, 1 $157.21
Montgomery,
Ohio 3658 Preble, Shelb
Coshocton,
Fai�eld, Fayette,
Knox, Madison, 1 $157.21
Morrow, Noble,
Ohio 3662 Per , Pickawa
Oklahoma 3753 Cleveland 1 $157.21
Canadian, 1 $157.21
Oklahoma 3754 Oklahoma
Bucks, Chester,
Delaware, 1 $157.21
Penns Ivania 3952 Mont ome
Denton, Hood, 1,030 $15721
Texas 4453 Tarrant
Texas 4454 Parker 93 $157.21
Collin, Dallas, 22 $15721
Texas 4455 Rockwall
Texas 4460 Bexar 4 $157.21
Austin, Harris,
Jefferson, Liberty, 5 $157.21
Texas 4464 Orange
Texas 4465 Galveston 1 $157.21
Texas 4467 Williamson 1 $157.21
Texas 4468 Travis 3 $157.21
Texas 4469 Ha s 1 $157.21
Texas 4471 Nueces 1 $157.21
Fairfax, Fairfax
City, Fauquier, 1 $157.21
Manassas City,
Virginia 4653 Prince William
National Average 1,181 $157.21
ME HMO GA (Y2013) 23 GRP 12 178
Exhibit A
January 1, 2013 — December 31, 2013
Evidence of Coverage:
Your Medicare Health Benefits and Services and Prescription Drug Coverage
as a Member of Aetna MedicaresM Plan (HMO).
This boolclet gives you the details about your Medicare health care and prescription drug
coverage from January 1, 2013 — December 31, 2013. It explains how to get coverage for the
health care services and prescription drugs you need. This is an important legal document.
Please keep it in a safe place.
This plan, Aetna Medicare Plan (HMO), is ofFered by Aetna Health Inc. or Aetna Health of
California lnc. (When this Evidence of Coverage says "we," "us," or "our," it means Aetna
Medicat•e. When it says "plan" or "our plan," it means Aetna Medicare Plan (HMO)).
Aetna Health Inc. and Aetna Health of California lnc. are Medicare Advantage organizations
with a Medicare contract.
This information is available for free in other languages. Please contact Member Services at the
telephone number printed on the back of your member ID card for additional information. You
may also call our general customer service center at 1-888-267-2637. (For TTY/TDD assistance,
please dial 711.) Hours are 8 a.m. to 6 p.m. in all time zones, Monday through Friday. Member
Services also has free language interpreter services available for non-English speakers.
Esta informacion esta disponible en otros idiomas de manera gratuita. Si desea mas informacion,
comuniquese con Servicios al Cliente al numet�o en el dorso de su tarjeta de identificacion de
miembro. Tambien puede llamat• a nuestro centro de servicio al cliente en general, al 1-888-267-
2637. (Los usuarios de TTY/TDD deben llamar al 711.) Nuestro horario de atencion es de 8
a.m. a 6 p.m. en todas las zonas horarias, el lunes por el viernes. Las pel•sonas que no hablan
ingles pueden solicitar el servicio gratuito de interpretes a Selvicios al Cliente.
This document may be made available in other formats such as Braille, lat•ge print or other
alternate formats. Please contact Member Services for more information.
Benefits, formulary, pharmacy network, premium, deductible, and/or copayments/coinsurance
may change on Januaty 1, 2014.
GRP 12 220 A 1 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Table of Contents
2013 Evidence of Covera�e
Table of Contents
This list of chapters and page numbers is yout� stat-ting point. For more help in finding
information you need, go to the first page of a chapter. You will find a detailed list of topics at
the beginning of each chapter.
Chapter1. Getting started as a member ....................................................................4
Explains what it means to be in a Medicare health plan and how to use this
booklet. Tells about materials we will send you, your plan premium, your plan
membership card, and keeping your membetship record up to date.
Chapter 2. Important phone numbers and resources ...............................................15
Tells you how to get in touch with our plan (Aetna Medicare Plan (HMO)) and
with other organizations including Medicare, the State Health Insurance
Assistance Program (SHIP), the Quality Improvement Organization, Social
Security, Medicaid (the state health insurance program for people with low
incomes), programs that help people pay for their prescription drugs, and the
Railroad Retirement Board.
Chapter 3. Using the plan's coverage for your medical services ...............................30
Explains important things you need to know about getting your medical care as a
member of our plan. Topics include using the provider�s in the plan's network and
how to get cat•e when you have an emergency.
Chapter 4. Medical Benefits Chart (what is covered and what you pay) .................42
Gives the details about which types of inedical care are covered and not covered
for you as a member of our plan. Explains how much you will pay as your share
of the cost for your covered medical care.
Chapter 5. Using the plan's coverage for your Part D prescription drugs ...............49
Explains rules you need to follow when you get your Part D drugs. Tells how to
use the plan's List of Covered Dy�ugs (Fo�°r�zzclary) to find out which dt•ugs are
covered. Telis which kinds of dt�ugs are not covered. Explains several kinds of
restrictions that apply to coverage for� certain drugs. Explains where to get your
prescriptions filled. Tells about the plan's programs fot� drug safety and managing
medications.
Chapter 6. What you pay for your Part D prescription drugs ..................................68
Tells about the four stages of drug coverage (Initial Cove�•crge Stage, Coverage
Gcrp Stcrge, Ccrtastrophic Covernge Stage) and how these stages affect what you
pay for your drugs. Explains the different cost-sharing tiers foi• your Part D drugs
and tells what you must pay for a drug in each cost-sharing tier. Tells about the
late enrollment penalty.
GRP_12 220 A 2 HMO EOC—with R�c (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Table of Contents
Chapter 7. Asking us to pay our share of a bill you have received for covered medical
servicesor drugs .......................................................................................86
Explains when and how to send a bill to us when you want to ask us to pay you
back for our share of the cost for your covered services or drugs.
Chapter8. Your rights and responsibilities ...............................................................93
Explains the rights and responsibilities you ha�e as a member of our plan. Tells
what you can do if you think your rights are not being respected.
Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals,
complaints) ................................................................................................103
Tells you step-by-step what to do if you are having problems or concerns as a
member of our plan.
Explains how to ask for coverage decisions and make appeals if you are having
trouble getting the medical care or prescription drugs you think are covered by
our plan. This includes asking us to make exceptions to the rules or extra
restrictions on your coverage for prescription drugs, and asking us to keep
covering hospital care and certain types of inedical services if you think your
coverage is ending too soon.
Explains how to make complaints about quality of care, waiting times, customer
seivice, and other concerns.
Chapter 10. Ending your membership in the plan ......................................................154
Explains when and how you can end your inembeiship in the plan. Explains
situations in which our plan is r•equired to end your membership.
Chapter11. Legal notices .............................................................................................162
Includes notices about governing law and about nondiscrimination.
Chapter 12. Definitions of important words ................................................................167
Explains key terms used in this booklet.
GRP 12 220 A 3 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna Medicat•eSM Plan (HMO)
Chapter 1: Getting started as a membet•
Chapter 1. Gettin� started as a member
SECTION 1 Introduction
Section 1.1 You are enrolled in Aetna Medicare Plan (HMO), which is a
Medicare HMO
Section 1.2 What is the Evidence of Coverage booklet about?
Section 13 What does this chapter tell you?
Section 1.4 What ifyou are new to our plan?
Section 1.5 Legal information about the Evidence of Coverczge
SECTION 2 What makes you eligible to be a plan member?
Section 2.1 Your eligibility requirements
Section 2.2 What are Medicare Part A and Medicare Pat�t B?
Section 2.3 The plan service area
SECTION 3 What other materials will you get from us
Section 3.1 Your plan membership card — Use it to get all covered care and
prescription drugs
Section 3.2 The Providei• Directory: Your guide to all providers and
pharmacies in the plan's network
Section 3.3 The plan's List of Cover•ed Di��ugs (For•mulary)
Section 3.4 The E�plancztion ofBenefits (the `BOB"): Reports with a summary
of payments made for your Part D prescription drugs
SECTION 4 Your monthly premium for our plan (if applicable)
Section 4.1 How much is your plan premium?
Section 4.2 There ar�e several ways you can pay your plan premium (if
applicable)
Section 43 Can we change your monthly plan premium (if applicable) during
the year?
SECTION 5 Please keep your plan membership record up to date
Section 5.1 How to help make sure that we l�ave accurate infot•mation about
you
SECTION 6 We protect the privacy of your personal health information
Section 6.1 We make sure that your health information is protected
SECTION 7 How other insurance works with our plan
Section 7.1 Which plan pays first when you have other insurance?
GRP_12 220 A 4 HMO EOC-witl� Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 1: Getting started as a member
SECTION 1 Introduction
Section l.l You are enrolled in Aetna Medicare Plan (HMO), which is a Medicare
HMO
Your coverage is provided through contract with your curr�ent employer ot• former employer/
union/trust. You are covered by Medicare, and you get your Medicare health care and
prescription dt�ug coverage through our plan, Aetna Medicare Plan (HMO).
There are different types of Medicare health plans. Our plan is a Medicare Advantage HMO Plan
(HMO stands for Health Maintenance Organization). Like all Medicare health plans, this
Medicare HMO is approved by Medicare and run by a pi•ivate company.
Section 1.2 What is the Evidence of Covet•age booklet about?
This Evidence of Cover�ccge booklet tells you how to get your Medicare medical care and
prescription dr�ugs covered through our plan. This booklet explains your rights and
responsibilities, what is covered, and what you pay as a member of the plan.
This plan, Aetna Medicare Plan (HMO), is offered by Aetna Medicare. (When this Evzdence of
Coverage says "we," "us," or "our," it means Aetna Medicare. When it says "plan" or "om�
plan," it means Aetna Medicare Plan (HMO).
The word "coverage" and "covered services" refers to the medical care and seivices and the
prescription drugs available to you as a member of our plan.
Section 1.3 What does this chapter tell you?
Look through Chapter 1 of this Evidence of Coverage to learn:
• What makes you eligible to be a plan member?
• What is your plan's setvice area?
• What materials will you get fi•om us?
• How to pay your plan premium (if applicable)
• How do you keep the information in your membership record up to date?
Section 1.4 What if you are new to our plan?
If you are a new member, then it's important fot� you to learn what the plan's rules are and what
services are available to you. We encourage you to set aside some time to look through this
Evidence of CoveNage booklet.
If you are confused or concerned or just have a question, please contact our plan's Member
Services (phone numbers are printed on the back cover of this booklet).
GRP 12 220 A 5 HMO EOC-with R� (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 1: Getting started as a member
Section 1.5 Legal information about the Evidence of Covef•age
It's part of our contract with you
This Evidence of Coverage is part of our contract with you about how our plan covers your care.
Other parts of this contract include your enrollment fot�m, the List of Covered Drugs
(Formulary), and any notices you receive fi•orn us about changes to your coverage or conditions
that affect your coverage. These notices are sometimes called "riders" or "amendments."
The contract is in effect for� months in which you are enr�olled in our plan between January l,
2013 - December 31, 2013.
Medicare must approve our plan each year
Medicare (the Centers for Medicare & Medicaid Services) must approve our plan each year.
Your former employer/unionitrust can continue to offer you Medicare coverage as a member of
our plan as long as we choose to continue to offer the plan and Medicare t�enews its approval of
the plan.
SECTION 2
Section 2.1
What makes you eligible to be a plan member?
Your eligibility requirements
Yort are eligible for naembe�ship zn our plan as long as:
• You live in the plan service area
• -- and -- you are entitled to Medicare Part A
• -- and -- you are enrolled in Medicare Part B
Section 2.2 What are Medicare Part A and Medicare Part B?
When you first signed up for Medicare, you received information about what services are
covered under Medicare Part A and Medicare Part B. Remember:
• Medicare Part A generally helps cover services furnished by institutional providers such
as hospitals (for inpatient services), skilled nuising facilities, or home health agencies.
• Medicat•e Part B is for most other medical ser•vices (such as physician's services and
other outpatient services) and certain items (such as durable medical equiprnent and
supplies).
Section 2.3 The plan service area
Although Medica��e is a federal pi•ogram, our plan is available only to individuals who live in our
plan service area. To remain a member of our plan, you must keep living in this service area. If
you tnove to outside of the selvice area, you will have a Special Enrollment Period that will
allow you to switch to a different plan. If you move outside of the ser�vice at�ea, please contact
Member• Services at the telephone nunzber on your� �nembet• ID card.
GRP_12 220 A 6 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter• 1: Getting started as a member
SECTION 3 What other materials will you get from us?
Section 3.1 Your plan membership card — Use it to get all covered care and
prescription drugs
While you are a member of our plan, you must use your membership card for our plan whenever
you get any services covered by this plan and for prescription drugs you get at network
pharmacies. Here's a sample membership card to show you what yours will look like:
.
�, .. � �^
MEDICARE 15 SPECIAL �r�\
HEHBER SIN s 2009\��
ID ME"""
NAME TES7 ��'[EST � �
RxBIf� -��10502 PCN ` A�\ `T `-
GR�'`�CXXXX �� S U
ISS ER (8084
MEDICARE HMO
f
l�
\\
ls�
14Zedicarel�
r«x.y�u>. oN c�-cw
�'`�� DR 10 ER 10
DR 760-242 `577 1509 SP 15 HO 10
�. � 1 as �o
3931 804
.ae�a�m
ea�ar� oo�er�se �s Pro�mea eyaeme xoann m�
Ez<�pt In emargencies or for direct a<cess ben��ss, roti
mus[ bb Issuad by �he pNmary cazo physician �PCP) yoG
ca Is pertormed, OR YDU WILL BE Rfi570N51BLE I
Be ofi4saraprovidetlundarthe�ertnsotfieapp(jr.-hle�.
intludingilmilecioneanaexciusions. Natwor:'� ��(
provttlers are independent conuaciors antl ar1\ e"thet`
EtAEHGENCYNRGEMLYNFFOED y, E: Calf�\jjl )
ihenearostemergencyfecE �Ila��woWai �.�
PCP. No�iNvovs.pcpasso��R� oo ��. eanert��2+n+ei
�
�
;�
79998-7106
Payarl0& b005d
nntl
wgaro
Yo��
m
IMPORTANTNUMBERS:
PROVIDER LINE: iBOO� 6Z�-O%SB
MEId9ER SERVICES: �8S$� 2G7-ZB$7
BENAVIORALHEALTH: �88H�261-263T
T�D LINE: t8$$� J60-�i%�IS
592}-0t)12
As long as you are a member of our plan you must not use your red, white, and blue
Medicare card to get covered medical services (with the exception of routine clinical research
studies and hospice services). Keep your red, white, and blue Medicare card in a safe place in
case you need it later.
Here's why this is so important: If you get covered services using your red, white, and blue
Medicare card instead of using your Aetna Medicare membership card while you are a plan
member, you may have to pay the full cost yourself.
If your plan inembership card is damaged, lost, or stolen, call Member• Services right away and
we will send you a new card. (Phone numbers for Member Services are printed on the back of
this booklet.)
Section 3.2 The Providet� Dif�ectoiy: Your guide to all providers and pharmacies in
the plan's network
Our network is a group of doctors, hospitals, and other health care experts and pharmacies
contracted by Aetna to provide covered setvices to its members. Network providers are
independent contractors and not agents of Aetna.
What are "network providers"?
Network providers are the doctors and other health care professionals, medical groups,
hospitals, and other health care facilities that have an agreement with us to accept our payment
and any plan cost sharing as payment in full. We have arranged for these providers to deliver
covered services to members in our plan.
GRP 12 220 A 7 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 1; Getting started as a member
Why do you need to know which providers are part of our network?
It is important to know which providers are part of out• network because, with limited exceptions,
while you are a member of our plan you must use network providers to get your medical care and
services. The only exceptions are emergencies, ut•gently needed care when the network is not
available (generally, when you are out of the area), out-of-ar�ea dialysis services, and cases in
which our plan authorizes use of out-of-network providets. See Chapter 3(Using the plan's
coverage for your� naedical servaces) for� mor•e specific information about emergency, out-of-
network, and oLtt-of-area coverage.
If you don't have your copy of the Provider Directory, you can request a copy from Mernber�
Services (phone numbers are printed on the back of this booklet). You may ask Member Services
for more information about our network provideis, including thei�• qualifications. You can also
see the Pr�ovide�� Directory at http://www.aetnaretireeplans.com, or download it from this
website. Both Member Seivices and the website can give you the most up-to-date information
about changes in our network providers.
What are "network pharmacies"?
Our Provider Directory gives you a complete list of our network pharmacies — that means ali of
the pharmacies that have agreed to fill covered presct•iptions for our plan members.
Why do you need to know about network pharmacies?
You can use the Pr�ovider Directory to find the network pharmacy you
important because, with few exceptions, you must get your prescriptions
netwot�k pharmacies if you want our plan to cover (help you pay for) them.
want to use. This is
filled at one of our
If you don't have the Pyovider• Directory, you can get a copy fi•om Membe
numbers are pr�inted on the back cover of this booklet). At any time, you
Services to get up-to-date inforrnation about changes in the pharmacy network.
this information on our website at http://www.aetnaretireeplans.com.
Section 3.3
The plan's List of Covered Drugs (Formulary)
r Services (phone
can call Member
You can also find
The plan has a List of Covered Dr�i�gs (Fornrzllcryy). We call it the "Drug List" for short. It tells
which Part D prescription drugs ar�e covered by our plan. The drugs on this list are selected by
the plan with the help of a team of doctors and pharmacists. The list must meet requirements set
by Medicat•e. Medicare has approved the Aetna Medicare Dt�ug List.
The Drug List also tells you if there are any rules that restrict coverage for yout� drugs.
We wiil send you a copy of the Drug List. The Drug List we send to you includes information for
the covered drugs that are most commonly used by our members. However, we cover additional
drugs that are not included in the printed Drug List. If one of youi• drugs is not listed in the Drug
List, you should visit our website or contact Metnbets Services to fmd out if we cover it. To get
the most complete and current information about which drugs are covered, you can visit the
plan's website (http://www.aetnaretireeplans.com) or call Membet• Setvices (phone numbers are
printed on the back cover of this booklet).
GRP_12_220 A 8 HMO EOC-wit11 RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
� Chapter 1: Getting started as a member
Sectiou 3.4 The Explanation of Behefrts (the "EOB"): Reports with a summary of
payments made for your Part D presci•iption drugs
When you use your Part D prescription drug benefits, we will send you a summaly r•eport to help
you understand and keep track of payments for your Part D prescription drugs. This summary
report is called the Explcrncrtion of Benefits (or the `BOB").
The Explanation of Benefits tells you the total amount you have spent on your Part D
prescription drugs and the total amount we have paid for each of your Part D pr�escription drugs
during the month. Chapter 6(Wh�rt you pay for youN PaNt D prescription drugs) gives more
information about the Explanation of Benefits and how it can help you keep track of your drug
coverage.
An Explanation of Benefzts summary is also available upon request. To get a copy, please contact
Membet� Services (phone numbers are pt•inted on the back cover of this booklet).
SECTION 4
Section 4.1
Your monthly premium for our plan (if applicable)
How much is your plan premium?
Your coverage is provided through a contt�act with your current employer or former employer/
union/trust. Your plan benefits administrator will let you know about your plan premium, if any.
If you have an Aetna plan premium and are billed du•ectly by Aetna Medicare for the full amount
of the premium, we will notify you of your plan premium amount before the start of the plan
year. If you have an Aetna plan premium and you are not billed directly by Aetna Medicare fot•
this premium, please 1•efer to your plan benefits administrator for any premium payment
information.
In addition, you must continue to pay yom� Medicare Part B premium (unless your Part B
premium is paid for you by Medicaid or another thir•d party).
In some situations, your plan premium could be less
There are programs to help people with limited resources pay for their drugs. These include
"Extra Help" and State Phar•maceutical Assistance Programs. Chapter 2, Section 7 tells more
about these programs. If you qualify, enrolling in the program might lower your� monthly plan
premium.
If you are alNeady en��olled and getting help from one of these programs, the information about
premiums in this Evidence of Covet�age may not apply to you. We send you a separate insert,
called the "Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription
Drugs" (also known as the "Low Income Subsidy Rider" or the "LIS Rider"), which tells you
about your drug coverage. If you don't have this insert, please call Member Services and ask for
the "LIS Rider." (Phone numbers for Member Services are printed on the back cover of this
booklet.)
GRP 12 220 A 9 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna Medicai•eSM Plan (HMO)
Chapter 1: Getting started as a member
In some situations, your plan premium could be more
Some members are required to pay a late enrollment penalty because they did not join a
Medicare drug plan when they first became eligible or because they had a continuous period of
63 days or more when they didn't have "creditable" prescription drug covet�age. ("Creditable"
ineans the drug coverage is at least as good as Medicare's standard dr•ug coverage.) For these
member•s, the late enrolltnent penaity is added to the plan's monthly �remium. Thei�� premium
amount will be the monthly plan premium plus the amount of their late enrollment penalty.
• If you are required to pay the late em•ollment penalty, the amount of your penaity depends
on how long you waited before you ent•olled in drug coverage or how many months you
were without drug coverage after you became eligible. Chapter 6, Section 10 explains the
late enroll»aent penalty.
• If you have a late enrollment penalty and do not pay it, you could be disenrolled from the
plan.
Many members are required to pay other Medicare premiums
In addition to paying the monthly plan prernium (if applicable), many members are required to
pay other Medicare premiums. As explained in Section 2 above, in order to be eligible for our
plan, you must be entitled to Medicare Pat•t A and enrolled in Medicare Part B. For that reason,
some plan membets (those who aren't eligible for premium-free Part A) pay a premium for
Medicare Part A. And most plan membet•s pay a premium for Medicare Part B. You must
continue paying your Medicare premiums to remain a member of the plan.
Some people pay an extra amount for Part D because of their yearly income. If your income is
$85,000 or above for an individual (or married individuals filing separately) or� $170,000 or
above for married couples, you must pay an extt•a amount d'u•ectly to the government (not the
Medicare plan) for your Medicare Part D coverage.
• If you are required to pay the extra amount and you do not pay it, you will be
disenrolled from the plan and lose prescription drug coverage.
• If you have to pay an extra amount, Social Security, not your Medicare plau, will send
you a letter telling you what that extra amount will be.
• For more information about Part D premiums based on income, go to Chapter 4, Section
11 ofthis booklet. You can also visit http://www.medicat�e.gov on the web oi• call 1-800-
MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-
877-486-2048. Or you may call Social Security at 1-800-772-1213. TTY users should
call 1-800-325-0778.
Your copy of Medicare & I'ou 2013 gives information about the Medicare premiutns in the
section called "2013 Medicare Costs." This explains how the Medicare Part B and Part D
prerniums differ for people with different incomes. Evetyone with Medicare receives a copy of
Medicare & You each year in the fall. Those new to Medicare receive it within a month aftet� first
signing up. You can also download a copy of Meclicar•e & You 2013 from the Medicare website
GRP_12 220 A 10 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
= Chapter 1: Getting started as a membet�
(http://www.medicare.gov). Or, you can order a printed copy by phone at 1-800-MEDICARE (1-
800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048.
Section 4.2 There are several ways you can pay your plan premium (if applicable)
Your coverage is provided through a contt•act with your current employer or former
employer/union/trust. For most members, your plan benefits administrator will provide you with
information about your plan premium (if applicable).
If Aetna bills you directly for your total plan premium, we will mail you a letter detailing your
premium amount. (You must also continue to pay your Medicare Pai•t B premium.) For
members who have an Aetna plan premium and are billed directly by Aetna, there are several
ways you can pay your plan premium, including by check, electronic payment or automatic
withdrawal. You may inform us of your premium payment option choice or change your choice
by calling Member Services at the nulnbers printed on the back of your member ID card. If you
decide to change the way you pay your premium, it can take up to three months for your new
payment method to talce effect. While we are processing your request for a new payment method,
you are responsible for making sure that your plan premium is paid on time.
What to do if you are having trouble paying your plan premium
If you are billed directly by Aetna, your plan premium is due in our office by the first day of the
month. If we have not received your premium by the first day of the month, we will send you a
notice telling you that your plan mernbership will end if we do not receive your premiuin within
a three-month period.
If you are having trouble paying your premium on time, please contact Member Services to see if
we can direct you to programs that will help with your plan premium. (Phone numbers for
Member Services are pt•inted on the back of this booklet.)
If we end your membership with the plan because you did not pay your plan premium, then you
may not be able to receive Part D coverage until the following year if you enroll in a new plan
during the annual enrollment period. During the annual enrollment period, you may either join a
stand-alone prescription drug plan or a health plan that also provides drug coverage. (If you go
without "creditable" drug coverage for more than 63 days, you may have to pay a late em•ollment
penalty for as long as you have Part D coverage.)
If we end your membership because you did not pay your premium, you will have health
coverage under Original Medicare.
At the time we end your membership, you may still owe us for premiums you have not paid. In
the future, if you want to enroll again in our plan (or another �lan that we offer), you may need to
pay the amount you owe before you can enroll.
If you think we have wt�ongfully ended your membership, you have a right to ask us to
reconsider this decision by making a complaint. Chapter 9, Section 10 of this boolclet tells how to
make a complaint. If you had an emergency circumstance that was out of your control and it
GRP 12 220 A 11 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chaptet� 1: Getting started as a member
_ _.
caused you to not be able to pay your premiums within our grace pet�iod, you can ask Medicare
to reconsider this decision by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7
days a week. TTY users should call 1-877-486-2048.
Section 4.3 Can we change your monthly plan premium (if applicable) during the
year?
No. We are not allowed to change the amount we charge for the plan's monthly plan premium
during the year. If the monthly plan premium changes for next year the change will take effect on
January 1 st.
However, in some cases the part of the premium that you have to pay can change during the year.
This happens if you become eligible for the Extra Help program or if you lose your eligibility for
the Extra Help program dur•ing the year. If a member qualifies for Extra Help with their
prescription drug costs, the Extra Help program will pay part of the member's monthly plan
pretnium. So a member who becomes eligible for Extra Help during the year would begin to pay
less towat�ds their tnonthly premium. And a member who loses their eligibility during the year
will need to start paying their full monthly premium. You can find out mor•e about the Extra Help
program in Chapter 2, Section 7.
SECTION 5
Section 5.1
Please keep your plan membership record up to date
How to help make sure that we have accurate information about you
Your membership record has information ft�om your enrollment form, including your address and
telephone number. It shows your specific plan coverage including your Primary Care
Provider/Medical Gt•oup/IPA. (An IPA, or Independent Practice Association, is an independent
group of physicians and other health-care providers under contr•act to provide services to
members of managed care organizations.)
The doctors, hospitals, pharmacists, and other providets in the plan's network need to have
correct information about you. These network providers use your membership record to
know what services aud drugs are coverecl ancl the cost-sharing amounts for you. Because
of this, it is very important that you help us keep your information up to date.
Let us know about these changes:
• Changes to your name, your address, or your phone number
• Changes in any other health insurance coverage you have (such as from your employer,
your spouse's etnployer�, workers' compensation, or• Medicaid)
• If you have any liability clairns, such as claims fi•om an auto�nobile accident
• If you have been admitted to a nur•sing home
• If you t•eceive care in an out-of-area or out-of-network hospital or emergency room
• If yout� designated responsible party (such as a caregiver) changes
• If you are participating in a clinical research study
GRP_12 220 A 12 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 1: Getting started as a member
If any of this information changes, please let us know by calling Member Services (phone
numbers are printed on the back of this booklet).
Read over the information we send you about any other insurance coverage you have
Medicare requires that we coliect information from you about any other medical or drug
insurance coverage that you ha�e. That's because we must coordinate any other coverage you
have with your benefits under our plan. (For more infot•mation about how our coverage worlcs
when you have other insurance, see Section 7 in this chapter.)
Once each year, we will send you a letter that lists any other tnedical or drug insurance coverage
that we know about. Please read over this information carefully. If it is correct, you don't need to
do anything. If the information is incorrect, or if you have other coverage that is not listed, please
call Member Services (phone numbers are printed on the back of yout� member ID card).
SECTION 6
Section 6.1
We protect the privacy of your personal health information
We make sure that your health information is protected
Federal and state laws protect the privacy of your medical records and personal health
information. We protect your pej•sonal health information as required by these laws.
Fot� more information about how we protect your personal health information, please go to
Chapter 8, Section 1.4 of this booklet.
SECTION 7
Section 7.1
How other insurance works with our plan
Which plan pays first when you have other insurance?
When you have other insurance (like coverage under another employer gt•oup health plan), there
are rules set by Medicare that decide whether our plan or your other insurance pays first. The
insurance that pays first is cailed the "primaiy payer" and pays up to the limits of its coverage.
The one that pays second, called the "secondary payer," only pays if there are costs left
uncovered by the primary coverage. The secondary payer may not pay all of the uncovered costs.
These rules apply for employer or union group health plan coverage:
• If you have retiree coverage, Medicare pays first.
• If your group health plan coverage is based on your or a family member's cuyrent
employment, who pays first depends on your age, the size ofthe employer, and whether
you have Medicare based on age, disability, or End-stage Renal Disease (ESRD):
• If you're under 65 and disabled and you or your family mernber is still working,
your plan pays fn�st if the employer has 100 oi• more employees or at least one
employer in a multiple empioyer plan has more than 100 employees.
GRP 12 220 A 13 HMO EOC-with I� (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 1: Getting stat�ted as a member
• If you're over 65 and you or yout• spouse is still working, the plan pays fitst if the
etnployer• has 20 or more employees ot• at least one employer in a tnultiple
employer plan has more than 20 employees.
• If you have Medicare because of ESRD, your group health plan will pay first for the first
30 tnonths after you become eligible for Medicare.
These types of cover�age usually pay first for services related to each type:
• No-fault insurance (including automobile insurance)
• Liability (including automobile insurance)
• Black lung benefits
• Workers' compensation
Medicaid and TRICARE never pay first for Medicare-covered setvices. They only pay after
Medicare, employer group health plans, and/or Medigap have paid.
If you have other insurance, tell your doctor, hospital, and pharmacy. If you have questions about
who pays fir�st, or you need to update your other insurance information, call Member Services
(phone numbers are printed on the back of your member ID card). You may need to give your
plan membet• ID number to your other insut•ers (once you have confirmed theu identity) so your
bills are paid cor�rectly and on time.
GRP_l2 220 A 14 HMO EOC—witti R�c (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 2: Important phone numbers and resources
__
Chapter 2. Important phone numbers and resources
SECTION 1 Aetna Medicare contacts (how to contact us, including how to reach Member
Services at the plan)
SECTION 2 Medicare (how to get help and information directly from the federal Medicare
program)
SECTION 3 State Health Insurance Assistance Program (fi•ee help, information, and
answers to your questions about Medicare)
SECTION 4 Quality Improvement Organization (paid by Medicare to check on the quality
of ca1�e for people with Medicare)
SECTION 5 Social Security
SECTION 6 Medicaid (a joint federal and state program that helps with medical costs for
some people with limited income and resources)
SECTION 7 Information about programs to help people pay for their prescription drugs
SECTION 8 How to contact the Railroad Retirement Board
SECTION 9 Do you have "group iusurance" or other health insurance from another•
employer/union/trust plan?
GRP 12 220 A 15 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 2: Important phone numbers and t�esources
SECTION 1 Aetna Medicare contacts (how to contact us, including how to
reach Member Services at the plan)
How to contact our plan's Member Services
For assistance with claims, billing or member card questions, please call or write to Aetna
Medicare Member Set•vices. We will be happy to help you.
` Member Services
'
CALL Please call the telephone number printed on the back of your member ID'
card. Or for questions regarding your medical benefits, call our general
customet� service center at 1-888-267-2637. For questions regarding your :,
1 prescription drug benefits, call 1-800-594-9390.
Calls to these numbers are fi�ee. Hours of operation: Monday tl�u•ough
Friday, 8 a.m. to 6 p.rn. in all time zones.
Membet• Seivices also has fi•ee language interpreter services available fot• ,':
'
non-English speakers. °;
TTY" ���.� .,. .
This number requires special telephone equipment and is only for people '
' who have difficulties with hearing or speaking.
' Calis to this number are fi•ee. Hours of oper�ation: Monday through '
� Friday, 8 a.m. to 6 p.m. in all time zones.
WRITE � Aetna�Medicare �
P.O. Box 14088
;� LeXington, KY 40512-4088
� ,
WEBSITE www.aetnaretireeplans.com ;
How to contact us when you are asking for a coverage decision about your medical care
A coverage decision is a decision we make about your benefits and coverage or about the amount
we will pay for your medical seivices. For more information on asking for coverage decisions
about your medical care, see Chapter 9(What to do if yozc have a pf•oblem or� con�plaint
(covef�age decisions, appeals, co»zplaints)).
GRP_12 220 A 16 HMO EOGwith R� (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 2: Important phone numbers and resources
You may call us if you have questions about our coverage decision process.
; Coverage Decisions for Medical Care
�,... , ..... . : , �. � _,. ,„ . ,_ ;
� CALL Please call the telephone number printed on the back of your member ID ;
4' card or our general customer service center at 1-888-267-2637.
; Calls to this number are $•ee. Hours of operation: Monday tlu•ough ;
Friday, 8 a.m. to 6 p.m. in all time zones.
Member Services also has fi•ee language interpreter services available for �
� non-English spealcers.
_ � _�. � _... �_. � �;. ._ �,., . .. ...
TTY 711
This number requires special telephone equipment and is only for people ;
who have difficulties with hearing or speaking.
:4 '
Calls to this number ar�e fi�ee. Hours of operation: Monday tlu•ough ;
Friday, 8 a.m. to 6 p.m. in all time zones. �
�;
.,:.._ . ,� _� � e .. . �, ....�. �..�z;.. _ �. _
WRITE Aetna Medicare Precertification Unit � `�
P.O. Box 14079
; Lexington, KY 40512-4079
How to contact us when you are making an appeal about your medical care
An appeal is a formal way of asking us to review and change a coverage decision we have made.
For more information on making an appeal about your medical care, see Chapter 9(What to do if
you have a problem or complaii�t (coverage c�ecisions, appeals, con�plaints)).
� Appeals for Medical Care
�
�
`� CALL 1-800-932-2159 for Expedited Appeals Only
,
�
Calls to this number are free. Hours of operation: 7 days per week, 8 a.m. to 8;:
;� p.m.
; _
, , . �.. n _
TTY 711 '
; This number requires speciai telephone equipment and is only for people who '
have difficulties with hearing ot• speaking.
�� Calls to this number are fi�ee. Hours of operation: 7 days per week, 8 a.m. to 8;
° p.in. ,
r,
;;; ;,
�„ . v ..�__ ,� . �, _ .. �. � �
�;
FAX 1-866-604-7092 =
GRP 12 220 A 17 HMO EOC-with I� (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 2: Important phone numbers and resources
WRITE Aetna Medicare Grievance & Appeal Unit
P.O. Box 14067
KY 40512
AETNA You can subtnit an appeal about our plan online. To submit an online appeal
WEBSITE go to:
http://www.aetnamedicare.com/plan_choices/advantage_appeals_grievances j
How to contact us when you are malung a complaint about your medical care
You can make a complaint about us or one of our netwot�k provider�s, including a complaint
about the quality of your care. This type of complaint does not involve coverage or payment
disputes. (If your pt�oblem is about the plau's coverage or payment, you should look at the
section above about making an appeal.) For tnore information on making a complaint about your
medical care, see Chapter 9(What to do if you have a pr�oblen� or� complaint (coverage decisions,
appeals, con2plaints)).
_ _ _ . __
Complaints about Medical Care
CALL Please call the telephone number printed on the back of your member ID;
'� card or our general customer service center at 1-888-267-2637.
j
Calis to this number are free. Hours of operation: Monday through Friday, 8;�
`' a.m. to 6 p.m. in all time zones.
;
TTY 7ll
i
�; This number requi�-es special telephone equipment and is only for people �
who have difficulties with hearing or speaking.
Calls to this number are fi•ee. Hours of opei•ation: Monday tht•ough Friday, 8�
a.m. to 6 p.tn. in all ti�ne zones. �I
FAX 1-866-604-7092
WRITE Aetna Medicare Grievance & Appeal Unit
I P.O. Box 14067
Lexington, KY 40512 „�
AETNA You can submit a complaint about oiu plan online. To submit an online ..
WEBSITE complaint go to:
http:!/www.aetnamedicat•e. com/p lan_choicesladvantage_appeals_grievance
�:
s.jsp
MEDICARE You can submit a complaint about our plan directly to Medicai•e. To subrnit ,;
WEBSITE an online complaint to Medicare go to: ;;
www.medicat•e.gov/MedicareComplaintFortn/home.aspx. ,
GRP 12 220 A 18 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for� Aetna Medicat�eSM Plan (HMO)
Chapter 2: Important phone numbet•s and resources
How to contact us when you are asking for a coverage decision about your Part D
prescription drugs
A coverage decision is a decision we make about your benefits and coverage or about the amount
we will pay for your Par•t D prescription drugs. For more information on asking for coverage
decisions about your Part D prescription drugs, see Chapter 9(YVhat to do if you have a pr�oblem
or cofnplaint (cover°age decisions, appeals, complaints)).
� Coverage Decisions for Part D Prescription Drugs
;; CALL 1-800-414-2386
��
�� Calls to this number are free. Hours of operation: Monday through ;
�
� Friday, S a.m. to 8 p.m. Eastern hme �
�, , � _ ,... m. _.�. _ � . �_�_ .. �
' TTY � 7ll � �� �
;
�
This number requu•es special telephone equipment and is only for people ;
; who have difficulties with hearing o1� speaking.
,
j
Calls to this number are free. Hours of operation: Monday tht�ough ;
� Friday, 8 a.m. to 8 p.m. Eastern time ;
$ �
.. . �, . . e�..�. , � _
3 � FAX �� 1-800-408-2386
� :
� , � �. � � , , �
WRITE � Pharmacy Management Precertificati �
�,
on Unit
�; 300 Highway 169 South, Suite 500
� Minneapolis, MN 55426 =
`� WEBSITE www.aetnamedicare.com ?
:�
How to contact us when you are making an appeal about your Part D prescription drugs
An appeal is a formal way of asking us to review and change a coverage decision we have made.
For more information on making an appeal about your Part D prescription drugs, see Chapter 9
(What to do if yoai hccve cz pt�oble��a of° complaint (coverage c�'ecisions, appec�ls, complaints)).
Appeals for Part D Prescription Drugs
CALL
1-877-235-3755 for Expedited Appeals Only
Calis to this number are free. Houts of operation: 7 days per week, 8 a.m. to 8
p.m.
GRP 12 220 A 19 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 2: Important phone numbeis and resources
TTY 711
This number requires special telephone equi�ment and is only for people who
have difficulties with hearing or speaking.
Calls to this number ar•e ft•ee. Hoitrs of operation: 7 days pet• week, 8 a.m. to 8,.
� p.m.
FAX 1-866-604-7092 ,
WRITE Aetna Medicare Pharmacy Grievance and Appeals Unit
P.O. Box 14579
' Lexin on KY 40512
� ,
� WEBSITE You can submit an appeal online. To submit an online appeal go to:
http://www.aetnamedicare.com/plan_choices/advantage_appeals_grievances.j ;
sp
How to contact us when you are making a complaint about your Part D prescription drugs
You can make a complaint about us or• arle of our network pharmacies, including a complaint
about the quality of your care. This type of complaint does not itivolve coverage or payment
disputes. (If your problem is about the plan's coverage or payment, you should look at the
section above about making an appeal.) For more infot•mation on rnaking a coinplaint about your
Pat•t D prescription drugs, see Chapter 9(What to do if yoz� have a problem or complaint
(covercrge decisions, appeals, conz�laints)).
Complaints about Part D prescription drugs
CALL Please call the telephone number printed on the back of your member ID
card or out� member service center at 1-800-594-9390.
Calls to this number are free. Houts of operation: Monday tlu•ough Ft•iday,
8 a.m. to 6 p.m. in all time zones.
TTY 711
This number requi��es special telephone equipment and is only for people ;
who have difficulties with hearing or speaking.
Calls to this number are fi•ee. Hours of opei•ation: Monday through Friday,
8 a.m. to 6 p.m. in all ti�ne zones.
FAX 1-866-604-7092
GRP_12 220 A 20 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 2: Important phone numbeis and resources
WRITE Aetna -
� Medicare Pharmacy Grievance and Appeal Unit
P.O. Box 14579
�� Lexington, KY 40512
! AETNA You can submit a complaint about our plan online. To subinit an onlme �
WEBSITE complaint go to:
� http://www.aetnamedicare.com/plan_choices/advantage_appeals_grievance j
; . ;
i S �Sp '
� MEDICARE You can submit a complaint about our plan directly to Medicat•e. To submit ;
�� WEBSITE an online complaint to Medicare go to:
� www.medicare.gov/MedicareComplaintForm/home.aspx.
i
Where to send a request asking us to pay for our share of the cost for medical care or a
drug you have received
For more inforrnation on situations in which you may need to ask us for reimbursement or to pay
a bill you have received fi•om a provider•, see Chapter 7(Asking us to pery ouY shcrf�e of a bill you
have received for covered n�ecliccrl ser-vices or drugs).
Please note: If you send us a payment request and we deny any part of your• request, you can
appeal our decision. See Chapter 9(What to do if you hcrve cr problem or� complcrint (coves•crge
decisions, appecrls, con�plaints)) for more information.
Payment Requests
.
.I._ _
For Prescription Drug Claims:
Aetna Medicare Prescription Drug Claim Processing Unit
P.O. Box 14023
Lexington, KY 40512
For Medical Claims:
/:�
P.O. Box 981106
El Paso, TX 79998-1106
SECTION 2 Medicare (how to get help and inforination directly from the
federal Medicare program)
Medicare is the federal health insurance program for people 65 years of age or older, some
people under age 65 with disabilities, and people with End-Stage Renal Disease (permanent
kidney failure requiring dialysis or a kidney transplant).
The federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services
(sometimes called "CMS"). This agency contracts with Medicare Advantage organizations
including us.
GRP 12 220 A 21 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage fot� Aetna MedicareSM Plan (HMO)
Chapter 2: Important phone numbet�s and resources
__ __ _ _
I►� [�i�t�'i'��
CALL 1-800-MEDICARE, or 1-800-633-4227
Calls to this number at•e fi�ee.
24 hours a day, 7 days a week.
TTY 1-877-486-2048
This number requires special telephone equipment and is only for people
who have difficulties with hearing or speaking.
Calls to this number are free.
WEBSITE http://www.medicare.gov
This is the official government website for Medicare. It gives you up-to-
date information about Medicare and current Medicare issues. It also has
information about hospitals, nursing homes, physicians, home health
agencies, and dialysis facilities. It includes booklets you can print d'u•ect(y
from your computer. You can also find Medicare contacts in your• state.
The Medicare website also has detailed information about your Medicare
eligibility and enrollment options with the following tools:
• Medicare Eligibility Tool: Pt�ovides Medicare eligibility status
information.
• Medicare Plan Finder: Provides personalized information about
available Medicare prescription drug plans, Medicare healtll
plans, and Medigap (Medicare Supplement InsuT�ance) policies in
your area. These tools provide an estin2ate of what yout• out-of-
pocket costs might be in different Medicare plans.
You can also use the website to tell Medicare about any complaints you
have about our plan:
• Tell Medicare about your complaint: You can submit a
complaint about our plan directly to Medicare. To subinit a
complaint to Medicare, go to
www.medicare.gov/Medicat�eCo mp laintForm/home.aspx.
Medicare takes your� complaints seriously and will use this
infot•mation to heip improve the quality of the Medicare progran7.
If you don't have a computer, your local library or senior center may be
able to help you visit this website using its computer. Or, you can call
Medicare and tell the�n what information you are looking foz•. They will
find the infot•mation on the website, print it out, and send it to you. (You
can call Medicare at 1-800-NIEDICARE (1-800-633-4227), 24 hours a
dav, 7 days a week. TTY uset�s should call 1-877-486-2048.1
GRP_12 220 A 22 HMO EOC-with Rx (Y2013)
2013 Evidence of Cover•age for Aetna MedicareSM Plan (HMO)
° Chapter 2: Important phone numbers and t•esources
SECTION 3 State Health Insurance Assistance Program (free help,
information, and answers to your questions about Medicare)
The State Health Insurance Assistance Progt�am (SHIP) is a government pt•ogram with trained
counselors in evety state. Refer to Addendum A at the back of this Evidence of Coverage for the
name of the State Health Insurance Assistance Program in your state.
A SHIP is independent (not connected with any insurance company or health plan). It is a state
program that gets money fi•om the federal government to give fi•ee local health insurance
counseling to people with Medicare.
SHIP counselors can help you with your Medicare questions or problems. They can help you
understand your Medicare rights, help you make complaints about your medical care or
treatment, and help you straighten out problems with your Medicare bills. SHIP counselors can
also help you understand your Medicare plan choices and answer questions about switching
plans.
SECTION 4 Quality Improvement Organization (paid by Medicare to
check on the quality of care for people with Medicare)
There is a Quality Improvement Organization for each state. Refer to the Addendum A at the
back of this Evidence of Covercrge for the name of the Quality Improvement Organization in
your state.
A QIO has a group of doctors and other health care professionals who are paid by the federal
government. This organization is paid by Medicare to check on and help improve the quality of
care for people with Medicare. A QIO is an independent organization. It is not connected with
our plan.
You should contact the QIO in your state in any of these situations:
• You have a complaint about the quality of care you have received.
• You think coverage for your hospital stay is ending too soon.
• You think coverage for yom� home health care, skilled nur•sing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services are ending too soon.
SECTION 5 Social Security
Social Security is responsible for determining eligibility and handling enrollment for Medicare.
U.S. citizens who are 65 ot� older, or who have a disability or End-Stage Renal Disease and meet
certain conditions, are eligible for Medicare. If you are ah•eady getting Social Security checks,
enrollment into Medicare is automatic. If you are not getting Social Security checks, you have to
enroll in Medicare. Social Security handles the enrollment process for Medicare. To apply for
Medicare, you can call Social Security or visit your local Social Security office.
GRP 12 220 A 23 HMO EOC—with R7c (Y2013)
2013 Evidence of Covet�age fot� Aetna Medicai•eSM Plan (HMO)
Chapter 2: Important phone numbeis and resources
Social Security is also responsible fot� determining who has to pay an extra amount fot• their Part
D drug coverage because they have a higher income. If you got a letter from Social Security
telling you that you have to pay the extra amount and have questions about the amount or if your
income went down because of a life-changing event, you can call Social Security to ask for a
reconsideration.
,; Social Security
_�
� � CALL f 1-800-772-1213 �� � �
i
'
Calls to this number are free.
Available 7:00 am to 7:00 pm, Monday through Friday.
�
You can use Social Security's automated telephone ser-vices to get ;
recorded information and conduct some business 24 hours a day.
�i TTY 1-800-325-0778
�j This number requu•es special telephone equipment and is only for people �
who have difficulties with hearing or speaking.
� Calls to this number a��e free.
7
Available 7:00 am to 7:00 pm , Monday through Friday.
;:,
WEBSITE htt�://www.ssa.gov
SECTION 6 Medicaid (a joint federal and state program that helps with
medical costs for some people with limited income and
resottrces)
Medicaid is a joint federal and state government program that helps with medical costs for
cet•tain people with limited incomes and resout•ces. Some people with Medicare are also eligible
for Medicaid.
In addition, there are programs offered through Medicaid that help people with Medicare pay
their Medicare costs, such as their Medicare premiums. These "Medicare Savings Programs"
help people with limited income and resources save money each year:
• Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B
premiums, and other cost sharing (like deductibles, coinsurance, and copayments). (Some
people with QMB are also eligible for full Medicaid benefits (QMB+).)
Specified Low-Income Medicare Beneficiary (SLMB): Helps pay Part B premiums.
(Some people with SLMB are also eligible fot• full Medicaid benefits (SLMB+).)
GRP_l2_220 A 24 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicaresM Plan (HMO)
Chapter 2: Important phone numbers and resources
• Qualified Individual (Qn: Helps pay Part B premiums.
• Qualified Disabled & Working Individuals (QDVVI): Helps pay Part A premiums.
To find out more about Medicaid and its programs, contact your state Medicaid agency. Contact
inforination is in Addendum A in the back of this Evidence of Covercrge.
SECTION 7 Information about programs to help people pay for their
prescription drugs
Medicare's "Extra Help" Program
Medicare provides "Extr�a Help" to pay prescription drug costs for people who have limited
income and resources. Resources include your savings and stocks, but not your• home or car. If
you qualify, you get help paying for any Medicare drug plan's monthly premium, yearly
deductible, and prescription copayments. This Extra Help also counts toward your out-of-pocket
costs.
People with limited income and resources may qualify for Extra Help. Some people
automatically qualify for Extra Help and don't need to apply. Medicare mails a letter to people
who autornatically qualify for Extra Help.
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see
if you qualify for getting Extra Help, call:
• 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours
a day, 7 days a week;
• The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday through
Friday. TTY users should call 1-800-325-0778; or
• Your State Medicaid Office. (See Section 6 of this chapter for contact information.)
If you believe you have qualified foi• Extra Help and you believe that you are paying an incort�ect
cost-sharing amount when you get your prescription at a pharmacy, out� plan has established a
process that allows you to either request assistance in obtaining evidence of your proper co-
payment level, or, if you already have the evidence, to provide this evidence to us.
• While you are at the pharmacy, you can aslc the pharmacist to contact Aetna at the
number on your ID card. If the situation cannot be resolved at that time, Aetna will give
you a one-time exception and you will be charged the copayment/coinsurance amount
that you were given by CMS. This exception is temporary and lasts 21 days. Aetna will
permanently update our systems upon the receipt of one of the acceptable forms of
evidence listed below.
GRP 12 220 A 25 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 2: Important phone numbers and resources
You can fax your evidence to Aetna at 1-888-665-6296, or mail your doculnentation to:
Aetna Medicare Departinent
Attention: BAE
P.O. Box 14088
Lexington, KY �0512-4088
Examples of evidence can be any of the following items:
• A copy of yout� Medicaid card that includes your name and an eligibility date
during a month after June of the previous calendar year
• A copy of a state document that confirms active Medicaid status during a month
after June of the previous calendar year
• A print out from the state electronic enrollment file showing Medicaid status
during a month after June of the previous calendar� year
• A screen print from the state's Medicaid systetns showing Medicaid status during
a month aftet� June of the previous calendar year
• Other documentation provided by the state showing Medicaid status duruig a
month after June of the previous calendar year
• For individuals who at�e not deetned eligible, but who apply and are found LIS
eligible, a copy of the SSA award letter
• If you are institutionalized and qualify fot• zero cost-sharing:
• A remittance from the facility showing Medicaid payment for a full
calendar month for that individual during a month after June of the
previous calendar year
• A copy of a state document that confirms Medicaid payment on your
behalf to the facility for a full calendar month aftet• June of the previous
calendar year
• A screen pt�int fi�om the state's Medicaid systems showing your
institutional status based on at least a full calendar nlonth stay for
Medicaid payment purposes during a month aftet• June of the previous
calendar year
CMS and additional SSA documents that support a beneficiary's LIS cost sharing
level:
• Deeming notice — pub.no. 11166 (purple notice)
• Auto-ent�ollnzent notice — pub.no.11154 (yellow notice)
• Full-facilitated notice — pub.no. 11186 (green notice)
• Partial-facilitated notice — pub.no.11191 (green notice)
• Copay change notice — p�tb.no. l 1199 (oi•ange notice)
GRP_12_220 A 26 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 2: Important phone numbers and resout•ces
• Reassignment notice — pub.no. ll208 and 11209 (blue notice)
• When we receive the evidence showing your copayment level, we will update our system
so that you can pay the correct copayment when you get your next prescription at the
pharmacy. If you ovet�pay your copayment, we will reimburse you. Either we will
forward a check to you in the amount of your overpayinent or we will offset future
copayments. If the pharmacy hasn't collected a copayment fi•om you and is carrying your
copayment as a debt owed by you, we may make the payment directly to the pharmacy. If
a state paid on your behalf, we may make payment di�•ectly to the state. Please contact
Member Setvices if you have questions (phone numbets are printed on the back cover of
this booklet).
Medicare Coverage Gap Discount Program
The Medicare Coverage Gap Discount Program is available nationwide. If your Aetna Medicare
I2Y plan offers additional gap coverage during the Coverage Gap Stage, your out-of-pocket costs
will sometimes be lower than the costs described here. Please go to Chapter 4, Section 6 for
more information about your coverage during the Coverage Gap Stage.
The Medicare Coverage Gap Discount Pr•ogram provides manufacturer discounts on br•and name
drugs to Par�t D enrollees who have reached the coverage gap and are not alt•eady receiving
"Extra Help." A 50% discount on the negotiated price (excluding the dispensing fee and vaccine
administration fee, if any) is available for those brand name drugs fi•om manufacturels that have
agreed to pay the discount. The plan pays an additional 2.5% and you pay the remaining 47.5%
for your• brand drugs.
If you reach the coverage gap, we will automatically apply the discount when yout• pharmacy
bills you for your prescription and your Explanation of Benefits (EOB) will show any discount
provided. Both the amount you pay and the amount discounted by the manufacturer count toward
your out-of-pocket costs as if you had paid them and moves you through the coverage gap.
You also receive some coverage for generic drugs. If you reach the coverage gap, the plan pays
21 % of the price for generic drugs and you pay the remaining 79% of the price. The coverage for
generic drugs works differently than the coverage for brand name drugs. For generic drugs, the
amount paid by the plan (21 %) does not count toward your out-of-pocket costs. Only the amount
you pay counts and moves you thr�ough the coverage gap. Also, the dispensing fee is included as
part of the cost of the drug.
If you have any questions about the availability of discounts for the drugs you are taking or about
the Medicare Coverage Gap Discount Program in general, please contact Member Services
(phone numbers are printed on the back cover of this booklet).
What if you have coverage from a State Pharmaceutical Assistance Program (SPAP)?
If you are enroiled in a State Pharmaceutical Assistance Program (SPAP), or any other program
that provides coverage for Part D drugs (other than Extra Help), you still get the 50% discount on
covet�ed brand name drugs. Also, the plan pays 2.5% of the costs of brand drugs in the coverage
GRP 12 220 A 27 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 2: Important phone numbet•s and resources
gap. The 50% discount and the 2.5% paid by the plan is applied to the price of the dr•ug before
any SPAP or other coverage.
What if you get Extra Help from Medicare to help pay your prescription drug costs? Can
you get the discounts?
No. If you get Extra Help, you already get coverage for your pi•escr•iption drug costs during the
coverage gap.
What if you don't get a discount, and you think you should have?
If you think that you have r�eached the coverage gap and did not get a discount when you paid for
your brand name drug, you should review your next Explanation of Benefits (EOB) notice. If the
discount doesn't appear on your Explanation of Benefits, you should contact us to make sut�e that
your� prescription records are correct and up-to-date. If we don't agree that you are owed a
discount, you can appeal. You can get help filing an appeal from your State Health Insurance
Assistance Program (SHIP) (telephone numbers are in Addendum A at the end of this Evidence
of Covei�age) ot• by calling 1-800-MEDIC�RE (1-800-633-4227), 24 houts a day, 7 days a week.
TTY users should call 1-877-486-2048.
State Pharmaceutical Assistance Programs
Many states have State Pharmaceutical Assistance
prescription drugs based on financial need, age, or
rules to pt�ovide drug coverage to its members.
Programs that help some people pay for
medical condition. Each state has different
These programs provide limited income and medically needy seniors and individuals with
disabilities financial help for prescription drugs. Refer to Addendum A at the back of this
Evidence of Coverage to identify if there is an SPAP in your state.
SECTION 8 How to contact the Railroad Retirement Boai•d
The Railroad Retirement Board is an independent federal agency that administers comprehensive
benefit pr•ograms for the nation's rail�oad workers and their families. If you have questions
regarding your benefits from the Railroad Retirement Board, contact the agency.
Railroad Retirement Board
CALL
TTY
1-877-772-5772
Calls to this number are free.
Available 9:00 ain to 3:30 pm, Monday through Ft•iday
If you have a touch-tone telephone, recorded information and
automated services are available 24 hours a day, including
weekends and holidays.
1-312-751-4701
GRP_12 220 A 28 HMO EOC-with iZY (Y2013)
2013 Evidence of Coverage fot� Aetna MedicareSM Plan (HMO)
Chapter 2: Important phone numbers and resources
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.
Calls to this number are not free.
WEBSITE http://ww�v.rrb
SECTION 9 Do you have "group insurance" or other health insurance
from another employer/union/trust plan?
If you (or your spouse) get benefits from your (or your spouse's) employer or retiree group, call
the employer/union benefits administrator or Member Services if you have any questions. You
can ask about your (or your spouse's) employer� or retiree health benefits, premiums, or the
eni•ollment period. (Phone numbers for Meinber Services are pr•inted on the back cover of this
booklet.)
If you have other presct•iption drug coverage through your (or your spouse's) employer or retiree
group, please contact that group's benefits administrator. The benefits administrator can help
you determine how your curt•ent prescription drug coverage will work with our plan.
GRP 12 220 A 29 HMO EOC-with R� (Y2013)
2013 Evidence of Coverage for Aetna Medicat�eSM Pian (HMO)
Chapter 3: Using the plan's coverage for your medical setvices
Chapter 3. Usin� the plan's covera�e for your medical services
SECTION 1 Things to know about getting your medical care covered as a member of our
plan
Section 1.1 What are "network providers" and "covered services"?
Section 1.2 Basic rules for getting your medical care covered by the plan
SECTION 2 Use providers in the plan's network to get your medical care
Section 2.1 You must choose a Primary Care Provider (PCP) to provide and
Section 2.2
oversee your medical care
What kinds of inedical cat�e can you get without getting approval in
advance from your PCP?
Section 2.3 How to get care fi�om specialists and other network providers
Section 2.4 How to get care fi•om out-of-network providers
SECTION 3 How to get covered services when you have an emergency or urgent need for
care
Section 3.1
Section 3.2
Getting care if you have a medical emergency
Getting care when you have an urgent need for care
SECTION 4 What if you are billed directly for the full cost of your covered services?
Section 4.1 You can ask us to pay our share of the cost of covered setvices
Section 4.2 If services are not covered by our plan, you must pay the full cost
SECTION 5 How are your medical services covered when you are in a"clinical research
SECTION 6
Section 6.1 What is a religious non-medical health care institution?
study"?
Section 5.1 What is a"clinical research study"?
Section 5.2 When you participate in a clinical research study, who pays for
what?
Rules for getting care covered in a"religious non-medical health care
institution"
Section 6.2
What care fi�oin a religious non-inedical health care institution is
covered by our plan?
SECTION 7 Rules for ownership of durable medical equipment
Section 7.1 Will you own the durable medical equipment a$er making a
certain nurnber of payments under our plan?
GRP_12_220 A 30 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna Medicat•eSM Plan (HMO)
Chapter 3: Using the plan's coverage for your medical setvices
SECTION 1 Things to know about getting your medical care covered as
a member of our plan
This chapter explains what you need to know about using the plan to get your medical care
coverage. It gives definitions of terms and explains the rules you will need to follow to get the
medical treatments, services, and other medical care that are covered by the plan.
For the details on what medical care is covered by our plan and how much you pay when you get
this care, use the benefits chart included with this Evidence of Cover�age. It's described in
Chapter 4(Medical Benefits Chczrt, 1-vhat is covered and what you pay). This bene�its chart is
also referred to as Aetna's Schedule of Copayments/Coinsurance.
Section l.l What are "network providers" and "covered services"?
Here are some definitions that can help you understand how you get the care and seivices that
are covered for you as a member of our plan:
• "Providers" are doctors and other health care professionals licensed by the state to
provide medical services and care. The term "providers" also includes hospitals and other
health care facilities.
• "Network providers" are the doctors and other health care professionals, medical
groups, hospitals, and other health care facilities that have an agreement with us to accept
our payment and your cost-sharing amount as payment in full. We have arranged for
these providers to deliver covered setvices to members in our plan. The providers in our
netwot•k generally bill us di1•ectly for care they give you. When you see a network
provider, you usually pay only your share of the cost for their services.
• "Covered services" include all the inedical care, health care services, supplies, and
equipment that are covered by our plan. Your covered setvices for medical care are listed
in the benefits chart described in Chapter 4.
Section 1.2 Basic rules for getting your medical care covered by the plan
As a Medicare health plan, our plan must cover all seivices covered by Original Medicare and
must follow Original Medicare's coverage rules.
Our plan will generally cover your medical care as long as:
• The care you receive is included in the plan's Medical Beneiits Chart (Schedule of
Copayments/Coinsurance) included with this Evidence of Covef�age).
• The care you receive is considered medically necessary. "Medically necessary" means
that the services, supplies, or drugs are needed for the prevention, diagnosis, or treatment
of your medical condition and meet accepted standards of inedical practice.
GRP 12 220 A 31 HMO EOC-with I� (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 3: Using the plan's coverage for your medical services
• You have a network primary care provider (a PCP) who is providing and
overseeing your care. As a member of our plan, you must choose a network PCP (for
more information about this, see Section 2.1 in this chapter).
• In most situations, your network PCP must give you approval in advance before
you can use other providers in the plan's network, such as specialists, hospitals,
skilled nuising facilities, or home health care agencies. This is called giving you a
"referral." For more information about this, see Section 23 of this chapter.
• Referrals from your PCP are not required for emergency care or urgently needed
care. There are also some other kinds of cat•e you can get without having approval
in advance from your PCP (for more information about this, see Section 2.2 of
this chapter).
• You must receive your care from a network provider (for more information about
this, see Section 2 in this chapter). In most cases, care you receive fi•om an out-of-
network provider (a provider who is not part of our plan's network) will not be covered.
Here af�e thr�ee exceptions:
• The plan covers emergency care or urgently needed care that you get from an out-
of-network provider. Fot� mor�e information about this, and to see what emergency
ot• urgently needed cat�e means, see Section 3 in this chaptet•.
• If you need medical care that Medicare requi��es our plan to cover and the
provider•s in our netwar•k cannot provide this care, you can get this care from an
out-of-network provider. Authorization should be obtained from the plan prior• to
seeking care. In this situation, you will pay the same as you would pay if you got
the care from a netwot�k provider. For information about getting appt�oval to see
an out-of-network doctor, see Section 2.4 in this chapter.
• Kidney dialysis seivices that you get at a Medicare-certified dialysis facility when
you are temporarily outside the plan's service area.
• The providers in our networlc are listed in the Provicler• Director}�.
• If you use an out-of-network providet�, yout• share of the costs for your covered
services may be higher.
• Please note: While you can get your cat•e fi•om an out-of-network pt•ovider, the
provider must be eligible to participate in Medicare. We cannot pay a provider
who is not eligible to participate in Medicare. If you go to a provider who is not
eligible to participate in Medicare, you will be r•esponsible for the full cost of the
setvices you receive. Check with your providet� before receiving services to
confirtn that they are eligible to participate in Medicare.
GRP_12 220 A 32 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 3: Using the plan's coverage for your medical services
SECTION 2 Use providers in the plan's network to get your medical
care
Section 2.1 You must choose a Primary Care Provider (PCP) to provide and
oversee your medical care
What is a"PCP" and what does the PCP do for you?
When you become a member of our plan, you must choose a plan provider to be your PCP.
Your PCP is a physician who meets state requirements and is trained to give you medical care.
Your PCP will also help you arrange or coordinate the rest of the covered services you get as a
member of our plan. For example, in order for you to see a specialist, you usually need to get
your PCP's approval first (this is called getting a"referral" to a specialist.)
Your PCP will provide most of your care and will help you arrange or coordinate the rest of the
covered services you get as a member of our plan. This includes:
• x-rays
• laboratory tests
• therapies
• car•e fi•om doctors who are specialists
• hospital admissions, and
• follow-up care.
"Coordinating" your services includes referring and consulting with other plan providers about
your health care needs. If you need certain types of covered services or supplies, you must get
approval in advance. In some cases, your PCP may need to obtain approval in advance from
Aetna. Since your PCP will provide and coordinate your medical care, you should have all of
your past medical records sent to your PCP's office.
How do you choose your PCP?
At the time of enrolhnent, you must select a network PCP. You can select a PCP from either the
PT�ovider• Dzrecto�y or by calling Member Setvices, anytime, for assistance. You can also select a
PCP by accessing our online Provic�er Directofy, DocFind, at http://www.aetnaretireeplans.cotn.
If you have not selected a PCP within 30 days after enrollment, a PCP may be selected for you;
however, you may change that selection by contacting Member Services. If there is a particular
plan specialist or hospital that you want to use, check first to be sure that your PCP makes
referrals to that specialist, or uses that hospital.
Changing your PCP
You may change your PCP for any reason, at any time. Also, it's possible that your PCP might
leave our plan's network of providers and you would have to find a new PCP.
GRP 12 220 A 33 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 3: Using the plan's coverage for your medical setvices
To change your PCP, call Member Ser•vices. When you call, be sut�e to tell Member Services if
you are seeing specialists or currently getting other covered services that were coordinated by
your PCP (such as home health services and durable medical equipment). They will check to see
if the PCP you want to switch to is accepting new patients. Member Services will change your
membership record to show the name of your new PCP and confirm when the change to your
new PCP will take effect.
If you are a member of a California HMO, the effective date of the PCP change is either the 1 st
or the 15th of the month, depending upon the date that Aetna receives the request. For members
of all other plans, the PCP change is effective on the day you make your change request.
Section 2.2 What kinds of inedical care can you get without getting approval in
advance from your PCP?
You can get services such as those listed below without getting approval in advance from your
PCP.
• Routine women's health care, which includes breast exams, screening mammograms (x-
rays of the breast), Pap tests, and pelvic exams as long as you get them from a network
provider.
• Flu shots and pneumonia vaccinations as long as you get them from a netwot�k providel•.
• Emergency services from network providers or fi�om out-of-network providets.
• Urgently needed care from in-network providers or from out-of-networlc providers when
network providers are temporarily unavailable or inaccessible, e.g., when you are
temporarily outside of the plan's service area.
• Kidney dialysis services that you get at a Medicare-certified dialysis facility when you
are temporarily outside the plan's setvice area. (If possible, please call Member Services
before you leave the service area so we can help arrange for you to have maintenance
dialysis while you are away. Phone numbers for Member Services are printed on the back
cover of this booklet.)
• Routine annual vision and hearing exams included in your plan.
Section 2.3 How to get care frotn specialists and other uetwork providers
A specialist is a doctot� who provides health care services for a specific disease or part of the
body. There are many kinds of specialists. Here are a few exainples:
• Oncologists, who care for patients with cancet•.
• Cat�diologists, who care for patients with heart conditions.
• Orthopedists, who care for patients with certain bone, joint, or muscle conditions.
When your PCP thinks you may need specialized treatment, your PCP will give you a t�eferral
(appi•oval in advance) to see a network plan specialist or• other health care provider or facility.
GRP_12_220 A 34 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 3: Using the plan's coverage for your medical services
For certain types of covered services or supplies, your PCP will need to get prior authorization
(prior approval) fi�om Aetna. These covered services at•e marked on the Benefits Chart included
with this Evidence of Coverage.
What if a specialist or another uetwork provider leaves our plan?
Sometimes a specialist, clinic, hospital or other network provider you are using might leave the
plan. If your assigned PCP is terminating fi�om the Aetna Medicare network, we will make a best
effort to notify you in writing 30-days in advance of the PCP termination effective date. If a
hospital, specialist ot� other type of participating network provider is terminating from the Aetna
Medicare network, we will make a best effort to provide written notification 30-days in advance
of the provider's termination effective date to all members who have received services from the
terminating provider at least twice in the last 12 months. You may contact Member Services at
the number on your ID card for assistance in selecting a new PCP or to identify other Aetna
Medicare participating providers. You may also look up participating providers using DocFind,
available on our website at http://www.aetnaretireeplans.com.
Section 2.4 How to get care from out-of-network providers
If you requu�e health care services that are not available from network providers, your PCP will
coordinate the necessaiy approval and referral to an out-of-network provider
SECTION 3 How to get covered services when you have an emergency
or urgent need for care
Section 3.1
Getting care if you have a medical emergency
What is a"medical emergency" and what should you do if you have one?
A"medical emergency" is when you, or any other prudent layperson with an average
knowledge of health and medicine, believe that you have medical symptoms that requu•e
immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb.
The medical symptoms may be an illness, injuty, severe pain, or a medical condition that is
quickly getting worse.
If you have a medical emergency:
• Get help as quickly as possible. Call 911
or hospital. Call for an ambulance if you
referral first from your PCP.
for help or go to the nearest emergency room
ieed it. You do not need to get approval or a
• As soon as possible, make sure that our plan has been told about your emergency.
We''need to follow up on your emergency care. You or someone else should call to tell us
about your emergency care, usually within 48 hours. Please call Member Setvices at the
number on your ID card.
What is covered if you have a medical emergency?
You may get covet�ed emergency medical care whenever you need it, anywhere in the United
GRP 12 220 A 35 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 3: Using the plan's coverage for your medical setvices
States ot• its territor�ies. Our plan covers ambulance seivices in situations where getting to the
etnergency room in any other way could endanger your health. For rnore information, see the
Medical Benefits Chart included with this Evidence of Coverage.
Our plan also covers emetgency tnedical care if you receive the care outside of the United States.
Please see Chapter 4 for more information.
If you have an emergency, we will talk with the doctors who are giving you emergency care to
help manage and follow up on your care. The doctors who are giving you emergency care will
decide when your condition is stable and the medical emergency is over.
After the emergency is over you are entitled to follow-up care to be sure your condition
continues to be stable. Your follow-up care will be covered by our plan. If your emergency care
is provided by out-of-network providers, we will try to arrange for network providers to take
over your care as soon as your medical condition and the circumstances allow.
What if it wasn't a medical emergency?
Sometimes it can be hard to know if you have a medical emer•gency. For example, you might go
in for elnergency care — thinking that your• health is in serious danger — and the doctor rnay say
that it wasn't a medical emergency after all. If it turns out that it was not an emergency, as long
as you reasonably thought your health was in serious danger, we will cover your care.
However, a$er the doctor has said that it was not an emergency, we will cover additional care
only if you get the additional care in one of these two ways:
• You go to a network provider to get the additional care.
• — or — the additional care you get is considered "urgently needed care" and you follow the
rules for getting this urgent care (for more information about this, see Section 3.2 below).
Section 3.2 Getting care when you have an urgent need for care
What is "urgently needed care"?
"Urgently needed care" is a non-emet�gency, unforeseen medical illness, injury, or condition, that
requi�•es immediate medical care. Urgently needed care may be fi.u•nished by in-network
providers or by out-of-network providers when networlc providers are temporarily unavailable or
inaccessible. The unforeseen condition could, for example, be an unforeseen flare-up of a known
condition that you have.
What if you are in the plan's service area when you have an urgent need for care?
In most situations, if you are in the plan's service area, we will cover urgently needed care only if
you get this care from a network providet• and follow the other rules described earlier in this
chapter. However, if the cu�cumstances are unusual oi• extraordinaty, and network provideis are
temporarily unavailable or inaccessible, we will cover urgently needed care that you get from an
out-of-network provider.
GRP_12 220 A 36 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 3: Using the plan's coverage for your medical setvices
What if you are outside the plan's service area when you have an urgent need for care?
When you are outside the service area and cannot get care from a network provider, om� plan will
cover urgently needed care that you get fi�om any provider.
Oul• plan also covers urgently needed care if you receive the care outside of the United States.
SECTION 4
Section 4.1
What if you are billed directly for the full cost of your
covered services?
You can ask us to pay our share of the cost of covered services
If you have paid more than yom• share for covered services, or if you have r•eceived a bill for the
full cost of covel�ed medicai services, go to Chapter 7(Asking us to pery oui� shay�e of a bill yoz�
hcrve received for covered mediccrl services or drugs) for information about what to do.
Section 4.2 If services are not covered by our plan, you must pay the full cost
Our plan covers all medical services that are medically necessary, are listed in the plan's Medical
Benefits Chart (this chart is included with this Evidence of Coverage), and are obtained
consistent with plan rules. You at•e responsible for paying the full cost of services that aren't
covered by our plan, eithet• because they are not plan covered services, or they were obtained
out-of-network and were not authorized.
If you have any questions about whether we will pay for any medical service or care that you are
considering, you have the right to ask us whether we will cover it before you get it. If we say we
will not cover your services, you have the right to appeal our decision not to cover your care.
Chapter 9(What to do if yoZt have a problem or complaint (coverage decisions, appeals,
complaints)) has more information about what to do if you want a coverage decision fi�om us or
want to appeal a decision we have ah•eady made. You may also call Member Services to get
mot�e information about how to do this (phone numbers are printed on the back cover of this
booklet).
For covered services that have a benefit limitation, you pay the full cost of any services you get
after you have used up your benefit for that type of covered service. Paying for costs once a
benefit limit has been reached will not count toward an out-of-pocket maximum Iimit. You can
call Member Services when you want to know how much of your benefit limit you have already
used.
SECTION 5
Section 5.1
How are your medical services covered when you are in a
"clinical research study"?
What is a"clinical research study"?
A clinical research study (also called a"clinical trial") is a way that doctors and scientists test
new types of inedical care, lilce how well a new cancer drug works. They test new medical care
GRP 12 220 A 37 HMO EOC-with Rs (Y2013)
2013 Evidence of Coverage for Aetna Medicai•eSM Plan (HMO)
Chapter 3: Using the plan's coverage for your medical services
procedures or drugs by asking for volunteers to help with the study. This kind of study is one of
the fmal stages of a research process that helps doctors and scientists see if a new approach
wor•ks and if it is safe.
Not all clinical research studies are open to members of our plan. Medicare first needs to approve
the research study. If you participate in a study that Medicare has not appt•oved, you will be
responsible for• payzng all costs for youN�articipcttion in the stzcciy.
Once Medicare approves the study, someone who works on the study will contact you to eYplain
more about the study and see if you meet the requirements set by the scientists who are running
the study. You can participate in the study as long as you meet the r•equn�ements for the study
ancl you have a full understanding and acceptance of what is involved if you participate in the
study.
If you participate in a Medicare-approved study, Original Medicare pays most of the costs fot• the
covered services you t•eceive as part of the study. When you are in a clinical research study, you
may stay enrolled in our plan and continue to get the rest of your care (the care that is not related
to the study) through our plan.
If you want to participate in a Medicare-approved clinical research study, you do not need to get
approval from us or your PCP. The providers that deliver your care as part of the clinical
reseat�ch study do not need to be part of out� plan's network of providets.
Although you do not need to get our plan's permission to be in a clinical research study, you do
need to tell us before you start participating in a clinical research study. Her�e is why you
need to tell us:
1. We can let you know whether the clinical research study is Medicare-approved.
2. We can tell you what services you will get fi•orn clinical research study providers instead
of fi•om our plan.
If you plan on participating in a clinical research study, contact Member Setvices (phone
nutnbers are printed on the back cover of this booklet).
Section 5.2 When you participate in a clinical research study, who pays for what?
Once you join a Medicare-approved clinical research study, you are covei•ed for routine iteins
and seivices you receive as part of the study, including:
• Room and board for a hospital stay that Medicare would pay for even if you weren't in a
study.
• An operation or other inedical procedure if it is part of the r�esearch study.
• Treatment of side effects and complications of the new care.
Original Medicare pays most of the cost of the covered setvices you receive as part of the study.
After Medicare has paid its share of the cost for these services, our plan will also pay for part of
the costs. We will pay the difference between the cost sharing in Original Medicare and your
GRP_12 220 A 38 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 3: Using the plan's coverage for your medical services
cost sharing as a member of our plan. This means you will pay the same amount for the services
you receive as part of the study as you would if you received these services fi•om our plan.
Here's an exanaple of hoiv the cost shat�ing works: Let's say that you have a lab test that costs
$100 as part of the research study. Let's also say that your share of the costs for this test is $20
under Original Medicare, but the test would be $10 under our plan's benefits. In this case,
Original Medicare would pay $80 for the test and we would pay another $10. This means that
you would pay $10, which is the same amount you would pay under our plan's benefits.
In order for us to pay for our share of the costs, you will need to submit a request for payment.
With your request, you will need to send us a copy of your Medicare Summary Notices or other
documentation that shows what services you received as part of the study and how much you
owe. Please see Chapter 7 for more information about submitting requests for payment.
When you are part of a clinical research study, neither Medicare nor our plan ��ill pay for any
of the following:
• Generally, Medicare will not pay for the new item or service that the study is testing
unless Medicare would cover the item or service even if you were not in a study.
• Items and services the study gives you or any participant for free.
• Items or services provided only to collect data, and not used in your direct health care.
For example, Medicare would not pay for monthly CT scans done as part of the study if
your medical condition would normally require only one CT scan.
Do you want to know more?
You can get more information about joining a clinical research study by reading the publication
"Medicare and Clinical Research Studies" on the Medicare website (http://www.medicare.gov).
You can also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY
users should call 1-877-486-2048.
SECTION 6 Rules for getting care covered in a"religious non-medical
health cat•e institution"
Section 6.1 What is a religious non-medical health care institution?
A religious non-tnedical health care institution is a facility that provides care for a condition that
would ot•dinarily be treated in a hospital or skilled nursing facility care. If getting care in a
hospital or a skilled nursing facility is against a member's religious beliefs, we will instead
provide coverage for care in a religious non-medical health car�e institution. You may choose to
pursue medical care at any time for any reason. This benefit is provided only for Part A inpatient
services (non-medical health care services). Medicare will only pay for non-medical health care
seivices provided by religious non-medical health car•e institutions.
GRP 12 220 A 39 HMO EOC-with Rs (Y2013)
2013 Evidence of Coverage for Aetna Medicar�eSM Plan (HMO)
Chapter 3: Using the plan's coverage for your medical seivices
Section 6.2 What care from a religious non-medical health care institution is
covered by our plan?
To get care from a religious non-medical health care institution, you must sign a legal document
that says you are conscientiously opposed to getting medical tt�eatment that is "non-excepted."
• "Non-excepted" medical care or treatment is any medical care or treatment that is
voluntcrry and not required by any federal, state, or local law.
• "Excepted" medical treatment is medical care or treatment that you get that is not
voluntary or is required under federal, state, or local law.
To be covered by our plan, the care you get fi�om a religious non-medical health care institution
must meet the following conditions:
• The facility providing the care must be certified by Medicat�e.
• Our plan's coverage of services you receive is limited to non-religiozrs aspects of care.
• If you get services from this institution that are pr•ovided to you in your home, our plan
will cover these services only if your condition would ordinarily meet the conditions for
coverage of seivices given by home health agencies that are not religious non-medical
health care institutions.
• If you get services from this institution that are provided to you in a facility, the
following conditions a�ply:
• You must have a medical condition that would allow you to receive covered
services for inpatient hospital care or skilled nutsing facility care
and — you must get approval in advance from our plan before you are admitted to
the facility or your stay will not be covered.
Medicare Inpatient Hospital coverage limits apply. See the Benefits Chart included with this
Evidence of Coverage.
SECTION 7
Section 7.1
Rules for ownership of durable medical equipment
Will you own the durable medical equipment after making a certain
number of payments under our plan?
Durable medical equipment includes items such as oxygen equipment and supplies, wheelchairs,
walkers, and hospital beds ot�dered by a provider for use in the home. Cel•tain items, such as
prosthetics, are always owned by the enrollee. In this section, we discuss other types of durable
medical equipment that must be rented.
In Original Medicare, people who rent cel•tain types of durable medical equipment own the
equiprnent after paying co-payments fot� the itetn for� 13 months. As a inember of our plan,
however, you usually will not acquire ownership of reiited dui•able medical equipment items no
GRP_12_220 A 40 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna Medicat�eSM Plan (HMO)
Chapter 3: Using the plan's coverage for your medical setvices
matter how many copayments you make fot� the item while a member of our plan. Under certain
limited circumstances we will transfer ownership of the durable medical equipment item. Call
Member Services (phone numbers are printed on the back cover of this booklet) to find out about
the requirements you must meet and the documentation you need to provide.
What happens to payments you have made for durable medical equipment if you switch to
Original Medicare?
If vou switch to Original Medicare after being a member of our plan: If you did not acqull•e
ownership of the durable medical equipment item while in our plan, you will have to make 13
new consecutive payments fot� the item while in Original Medicare in order to acquire ownership
of the item. Your previous payments while in our plan do not count toward these 13 consecutive
payments.
If you made payments for the dut�able medical equipment item under Original Medicat•e before
you joined our plan, these previous Original Medicare payments also do not count toward the 13
consecutive payments. You will have to make 13 consecutive payments for the item under
Original Medicare in order to acquu�e ownership. There are no exceptions to this case when you
return to Original Medicare.
GRP 12 220 A 41 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage fot� Aetna MedicareSM Plan (HMO)
Chapter 4: Medical Benefits Chart (what is covered and what you pay)
Chapter 4. Medical Benefits Chart (what is covered and what vou pav)
SECTION 1 Understanding your out-of-pocket costs for covered services
Section 1.1 Types of out-of-pocket costs you may pay for your covered
services
Section 1.2 What is your yearly plan deductible?
Section 1.3 What is the most you will pay for Medicare Part A
cover•ed medical services?
Section 1.4 Our plan does not allow providers to "balance bill" you
and Part B
SECTION 2 Use the Metlical Benefrts Chart to iind out what is covered for you and how
much you will pay
Section 2.1 Yout� medical benefits and costs as a member of the plan
Section 2.2 Getting care using our plan's optional visitot•/tt�aveler benefit
SECTION 3 What benefits are not covered by the plan?
Section 3.1 Benefits we do not cover (exclusions)
GRP_12 220 A 42 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna Medicat�eSM Plan (HMO)
Chapter 4: Medical Benefits Chart (what is covered and what you pay)
SECTION 1 Understanding your out-of-pocket costs for covered services
This chapter focuses on your covered services and what you pay for your medical beneiits. It
describes a Medical Benefits Chart that lists your covered seivices and shows how much you
will pay for each covered service as a member of our plan. The Medical Benefits Chart is
included with and is part of this Evidence of Coverage. (This benefits chart is also referred to as
Aetna's Schedule of Copayments/Coinsurance.) Later in this chapter, you can find information
about medical services that are not covered. It also explains limits on certain services.
Section 1.1 Types of out-of-pocket costs you may pay for your covered services
To understand the payment information we give you in this chapter, you need to know about the
types of out-of-pocket costs you may pay for your covered seivices.
• The "deductible" is the amount you must pay for medical services before our plan begins
to pay its share. (Section 1.2 tells you more about your yearly plan deductible.)
• A"copayment" is the fixed amount you pay each time you receive certain medical
seivices. You pay a copayment at the time you get the medical service. (The Medical
Benefits Chart tells you more about your copayments.)
• "Coinsurance" is the percentage you pay of the total cost of certain medical services.
You pay a coinsurance at the time you get the medical set�vice. (The Medical Benefits
Chart tells you more about your coinsurance.)
Some people qualify for State Medicaid programs to help them pay thei�• out-of-pocket costs for
Medicare. (These "Medicare Savings Programs" include the Qualified Medicare Beneficiary
(QMB), Speciiied Low-Income Medicare Beneficiaiy (SLMB), Qualifying Individual (QI), and
Qualified Disabled & Working Individuals (QDWI) programs.) If you are enrolled in one of
these programs, you may still have to pay a copayment for the service, depending on the rules in
your state.
Sectiou 1.2 What is your yearly plan deductible?
Your yearly deductible (if applicable) is listed on the Medical Benefits Chart (Schedule of
Copayments/Coinsurance) included with this Evidence of Coverage. If your plan has a
deductible, this is the amount you have to pay out-of-pocket before the plan will pay its shat�e for
your covered medical services.
Until you have paid the deductible amount, you must pay the full cost of your covered services.
Once you have paid your deductible, we will pay our share of the costs for covered medical
seivices and you will pay your share (your copayment or coinsurance amount) for the rest of the
calendar year.
The deductible does not apply to some setvices. This means that we will pay out• share of the
costs for these sezvices even if you haven't paid your yearly deductible yet. Refer to page 1 of
the Medical Benefits Chart for a full list of services that are not subject to the plan deductibles.
GRP 12 220 A 43 HMO EOC-with I� (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 4: Medical Benefits Chart (what is covered and what you pay)
Section 1.3 What is the most you will pay for Medicare Part A and Part B
covered medicalservices?
Because you at�e enrolled in a Medicar•e Advantage Plan, there is a limit to how much you have
to pay out-of-pocket each year for in-network medical services that are covered under Medicare
Part A and Part B(see the Medical Benefits Chart included with this Evidence of CoveNage).
This limit is called the maximum out-of-pocket amount for medical services.
• As a member of our plan, the most you will have to pay out-of-pocket for in-network
covered Part A and Part B services in 2012 is shown on the fn•st page of the Medical
Benefits Chart included with this Eviclence of Coverage. The amounts you pay for
copayments and coinsurance for� in-networ�k covered services count toward this maximum
out-of-pocket amount. (The amount you pay for your plan pt�emium, if applicable, does
not count toward your maximum out-of-pocket amount. In addition, amounts you pay for
some services do not count toward your maximum out-of-pocket amount. These services
are noted in the Medical Benefits Chart.) If you reach the maximum out-of-pocket
amount, you will not have to pay any out-of-pocket costs for the rest of the year for in-
network covered Pat•t A and Part B services. However, you must continue to pay your
plan premium, if applicable and the Medicare Part B premium (unless your Part B
premium is paid for you by Medicaid or another third parry).
Section 1.4 Our plan does not allow providers to "balance bill" you
As a member of our plan, an important protection for you is that, after you meet any deductibles,
you only have to pay your cost-sharing amount when you get ser•vices covered by our� plan. We
do not allow provider•s to add additional sepat•ate charges, called "balance billing." This
protection (that you never pay more than your cost-sharing amount) applies even if we pay the
provider less than the provider charges for a service and even if there is a dispute and we don't
pay certain provider charges.
Here is how this protection works.
• If your cost sharing is a copayment (a set amount of dollars, for example, $15.00), then
you pay only that amount for any covered services from a network provider.
• If youi• cost sharing is a coinsurance (a percentage of the total charges), then you never
pay rnore than that percentage. However, your cost depends on which type of provider
you see:
• If you receive the covered services frorn a network provider, you pay the
coinsurance percentage multiplied by the plan's reimbursement t•ate (as
determined in the contract between the provider and the plan).
• If you receive the covered services fi•om an out-of-network provider who
participates with Medicare, you pay the coinsurance percentage multiplied by the
Medicare payment rate for �articipating providers. (Remember, the plan covers
services from out-of-network providers only in certain situations, such as when
you get a referral.)
GRP_12 220 A 44 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 4: Medical Benefits Chart (what is covered and what you pay)
• If you receive the covered setvices fi•om an out-of-network provider who does not
participate with Medicare, you pay the coinsurance percentage multiplied by the
Medicare payment rate for non-participating providers. (Remember, the plan
covers services from out-of-network providers only in certain situations, such as
when you get a referral.)
SECTION 2 Use the Medic�l Benefits Chart to
for you and how much you will pay
Section 2.1
find out what is covered
Your medical benefits and costs as a member of the plan
The Medical Benefits Chart (also referred to as the Aetna Schedule of Copayments/
Coinsurance) included with this Evidence of Cover�age lists the services our plan covers and what
you pay out-of-pocket for each service. The services listed in the Medical Benefits Chart are
covered only when the following coverage requu•ements are met:
• Your Medicare covered seivices must be provided according to the coverage guidelines
established by Medicare.
• Your services (including medical care, services, supplies, and equipment) must be
medically necessary. "Medically necessary" means that the setvices, supplies, or drugs
are needed for the prevention, diagnosis, or treatment of your medical condition and meet
accepted standards of inedical practice.
• You receive your care from a network provider. In most cases, care you receive from an
out-of-network provider will not be covered. Chapter 3 provides more information about
requirements for using netwark providers and the situations when we will cover seivices
fi�om an out-of-network provider.
• You have a primary care provider (a PCP) who is providing and overseeing your care. In
most situations, your PCP must give you approval in advance before you can see other
providers in the plan's network. This is called giving you a"referral." Chapter 3 provides
more information about getting a referral and the situations when you do not need a
referral.
• Some ofthe services listed in the Medical Benefits Chart are covered only if your doctor
or other network provider gets approval in advance (sometimes called "prior
authorization") from Aetna Medicare. Covered seivices that need approval in advance to
be covered as in-network services are marked by an asterisk and footnote in the Medical
Benefits Chart.
Sometimes, Medicare adds coverage under Original Medicare for new services during the year.
If Medicare adds coverage for any services during 2013, either Medicare or our plan will cover
those services.
See the Medical Benefits Chart (also referred to as Aetna's Schedule of Copayments/
GRP_12 220 A 45 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 4: Medical Benefits Chart (what is covered and what you pay)
Coinsurance) included with this Evidence of Coverage for details.
Section 2.2 Getting care using our plan's optional visitor/traveler benefit
When you are continuously absent from out• plan's service area for� more than six months, we
usually inust disenroll you fi•om our plan. Howevet•, we offer� as a supplemental benefit a
visitor/traveler program that is in all of our approved Aetna Medicare HMO service areas, which
wi11 allow you to remain enrolled in our plan when you are outside of our service area for up to
12 months. This pr•ogram is available to all Aetna Medicare HMO members who are temporarily
in the visitor/traveler area. Under our visitor/traveler program you may receive all plan covered
services at in-network cost sharing. If you are traveling or temporarily residing outside your
service area for an extended period of time (no more than 12 consecutive months), please notify
Member Services to enroll in the U.S. Travel Advantage Program. Please contact the plan for
assistance in locating a provider when using the visitor/traveler beneiit.
If you are in the visitor/traveler area, you can stay em�olled in our plan for up to 12 months. If
you ha�e not retur•ned to the plan's service area within 12 months, you will be disem�olled frorn
the plan.
Member Services can help you select a PCP located in the Aetna Medicat�e HMO seivice area
where you will be so that you can access routine care. This PCP will coordinate your care while
you are traveling or temporarily residing in that service area. Upon your return to your home
service ar•ea, call Member Services to switch back to a PCP available in your� home service area.
Please contact Member Services for assistance in locating a provider when using the
visitor/traveler benefit.
SECTION 3
Section 3.1
What benefits are not covered by the plan?
Benefits we clo not cover (exclusions)
This section tells you what kinds of benefits are "excluded." Excluded means that the plan
doesn't cover these benefits.
The list below describes some services and items that at•en't covered under any conditions and
some that are excluded only under� specific conditions.
If you get benefits that are excluded, you must pay fot• them yoursel£ We won't pay for the
excluded medical benefits listed in this section (or elsewhet•e in this booklet), and neither will
Original Medicat�e. The only eYception: If a benefit on the exclusion list is found upon appeal to
be a medical benefit that we should have paid for or covered because of your specific situation.
(For information about ap�ealing a decision we have made to not covet• a medical service, go to
Chapter 9, Section 5.3 in this booklet.) �
In addition to any exclusions or limitations desc��ibed in the Benefits Chat�t, or anywhere else in
this Evidence of Coverage, the following items and services aren't covered under Original
Medicare or by our plan:
GRP_12 220 A 46 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 4: Medical Benefits Chart (what is covered and what you pay)
• Services considered not reasonable and necessary, according to the standards of Original
Medicare, unless these services are listed by our plan as covered services.
• Experimental medical and surgical procedures, equipment and medications, unless
covered by Original Medicare or under a Medicare-approved clinical research study or by
our plan. (See Chapter 3, Section 5 for more information on clinical research studies.)
Experimental procedur•es and items are those items and procedures determined by our
plan and Original Medicare to not be generally accepted by the medical community.
• Surgical treatment for morbid obesity, except when it is considered medically necessary
and covered under Original Medicare.
• Private room in a hospital, except when it is considered medically necessary.
• Private duty nurses unless purchased as additional plan coverage by your
employer/union/tt-ust group plan.
• Personal items in your room at a hospital or a skilled nur�sing facility, such as a telephone
or a television.
• Full-time nursing care in your home.
• Custodial care is care provided in a nursing home, hospice, or other facility setting when
you do not require skilled medical care or skilled nursing care. Custodial care is personal
care that does not require the continuing attention of trained medical or paramedical
personnel, such as car•e that helps you with activities of daily living, such as bathing or
dressing.
• Homemaker services include basic household assistance, including light housekeeping or
light meal preparation.
• Fees charged by your immediate relatives or members of your household.
• Meals delivet•ed to your home.
• Elective or voluntaty enhancement procedures or services (including weight loss, hair
growth, sexual performance, athletic pet�formance, cosmetic purposes, anti-aging and
mental performance), except when medically necessary.
• Costnetic suigery or procedures, unless because of an accidental injury or to improve a
malformed part of the body. However, all stages of 1•econstruction are covered for• a
breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical
appearance.
• Routine dental care, such as cleanings, fillings or dentures. However, non-routine dental
care required to treat illness or injury may be covered as inpatient or outpatient care.
GRP 12 220 A 47 HMO EOC—with R7c (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 4: Medical Benefits Chart (what is covered and what you pay)
• Chiropractic care, other than manual manipulation of the spine consistent with Medicare
coverage guidelines.
• Routine foot care, except for the limited coverage provided according to Medicare
guidelines unless purchased as additional plan coverage by your employer/union/trust
group plan.
• Orthopedic shoes, unless the shoes are part of a leg brace and are included in the cost of
the brace or the shoes are for a person with diabetic foot disease.
• Supportive devices for the feet, except for orthopedic or therapeutic shoes for people with
diabetic foot disease.
• Routine hearing exams, heat•ing aids, or exams to fit hearing aids (unless specifically
listed in the Benefits Chart).
• Eyeglasses, routine eye examinations, (unless specifically listed in the Benefits Chart,)
radial keratotomy, LASIK surgety, vision therapy and other low vision aids. However,
eyeglasses are covered for people after cataract suigely.
• Reversal of sterilization procedures, sex change operations, and non-prescr�iption
contraceptive supplies.
• Acupuncture.
• Naturopath services (uses natural or alternative treatments).
• Services provided to veterans in Veterans Affairs (VA) facilities. However, when
emergency seivices are r•eceived at a VA hospital and the VA cost sharing is rnore than
the cost sharing under our plan, we will reimburse veterans for the difference. Membets
are still resparisible for our cost-sharing amounts.
The plan will not cover the excluded setvices listed above. Even if you receive the set•vices at an
emergency facility, the excluded setvices ace still not covered.
GRP_12 220 A 48 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 5: Using the plan's coverage for your Part D prescription drugs
Chapter 5. Usin� the plan's covera�e for vour Part D prescription dru�s
SECTION 1 Introduction
Section 1.1
Section 1.2
This chapter describes your coverage for Part D drugs
Basic rules for the plan's Part D drug coverage
SECTION 2 Fill your prescription at a network pharmacy or through the plan's mail-
order service
Section 2.1 To have your prescription covered, use a network pharmacy
Section 2.2 Finding network pharmacies
Section 2.3 Using the plan's mail-order services
Section 2.4 How can you get a long-term supply of drugs?
Section 2.5 When can you use a pharmacy that is not in the plan's network?
SECTION 3 Your drugs need to be on the plan's "Drug List"
Section 3.1 The "Drug List" tells which Part D drugs are covet•ed
Section 3.2 There are different "cost-sharing tiers" for drugs on the Drug List
Section 3.3 How can you find out if a specific drug is on the Drug List?
SECTION 4 There are restrictions on coverage for some drugs
Section 4.1 Why do some drugs have restrictions?
Section 4.2 What kinds of restrictions?
Section 4.3 Do any of these restrictions apply to your drugs?
SECTION 5 What if one of your drugs is not covered in the way you'd like it to be
covered?
Section 5.1
Section 5.2
Section 5.3
Thet•e are things you can do if your drug is not covered in the way
you'd like it to be covered
What can you do if your drug is not on the Drug List or if the dr•ug
is restricted in some way?
What can you do if your drug is in a cost-sharing tiez� you think is
too high?
SECTION 6 What if your coverage changes for one of your drugs?
Section 6.1 The Drug List can change dut�ing the year
Section 6.2 What happens if coverage changes for a drug you are taking?
SECTION 7 What types of drugs are �zot covered by the plan?
Section 7.1 Types of drugs we do not cover
SECTION 8 Show your plan membership card when you �II a prescription
Section 8.1 Show your membership card
Section 8.2 What if you don't have your membership card with you?
GRP 12 220 A 49 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter• 5: Using the plan's coverage for your Par•t D pt•escription drugs
SECTION 9 Part D drug coverage in special situations
Section 9.1 What if you're in a hospital or a skilled nursing facility for a stay
that is covered by the plan?
Section 9.2 What if you're a resident in a long-term care facility?
Section 9.3 What if you're also getting drug coverage from another
employer/union/trust retiree group plan?
SECTION 10 Programs on drug safeiy and managing medications
Section 10.1 Programs to help members use dr•ugs safely
Section 10.2 Programs to help members manage their medications
GRP_12 220 A 50 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 5: Using the plan's coverage for your Part D prescription drugs
Did you know there are programs to help people pay for their drugs?
There are programs to help people with limited resources pay for their drugs.
These include "Extra Help" and State Pharmaceutical Assistance Programs. For
more information, see Chapter 2, Section 7.
Are you currently getting help to pay for your drugs?
If you are in a program that helps pay for your drugs, some information in this
Evidence of Coverage about the costs for Part D prescription drugs may not
apply to you. We send you a separate insert, called the "Evidence of Coverage
Rider for People Who Get Extra Help Paying for Prescription Drugs" (also known
as the "Low Income Subsidy Rider" or the "LIS Rider"), that tells you about your
drug coverage. If you don't have this insert, please call Member Services and ask
for the "LIS Rider." (Phone numbeis for Member Services are printed on the back
cover of this booklet.)
SECTION 1
Section 1.1
Introduction
This chapter describes your coverage for Part D drugs
This chapter explains rules for using your coverage for Part D drugs. The next chapter tells
what you pay for Pat•t D drugs (Chaptei• 6, What you pay for your Part D prescription drugs).
In addition to your coverage foi• Pat•t D drugs, our plan also covers sotne drugs under the plan's
medical benefits:
• The plan covers drugs you are given during covered stays in the hospital or in a slcilled
nursing facility. Chapter 4(Medical Benefits Chart, what is covered and what you pay)
tells about the benefits and costs for drugs during a covered hospital or skilled nursing
facility stay.
��
Medicare Part B also provides benefits for some drugs. Part B drugs include certain
chemotherapy drugs, certain drug injections you are given during an office visit, and
drugs you are given at a dialysis facility. Chapter 4(Medical Benefzts Chat�t, u�hat is
covered crnd what you pery) tells about your benefits and costs for Part B drugs.
The two examples of drugs described above are covered by the plan's medical benefits. The rest
of your prescription drugs are covered under the plan's Part D benefits.
Section 1.2
Basic rules for the plan's Part D drug coverage
The plan will generally cover your drugs as long as you follow these basic rules:
• You must have a provider (a doctor or� other prescriber) write your prescription.
• You must use a network pharmacy to fill your prescription. (See Section 2, Fill yoz�r
pJ�escNiptio�s at a nettvor�kphar��aacy o�• through the plan's n2ccil-ordef• sef�vice.)
GRP_12 220 A 51 HMO EOC—with Rac (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 5: Using the plan's coverage for your Part D prescription drugs
• Your drug must be on the plan's List of Covered Drugs (Formz�lary) (we call it the "Dtug
List" for short). (See Section 3, Your drugs need to be on the plan's "Drug List. ")
• Your drug must be used for a medically accepted indication. A"medically accepted
indication" is a use of the drug that is either appr�oved by the Food and Drug
Administration or supported by certain t�eference books. (See Section 3 for more
information about a medically accepted indication.)
SECTION 2 Fill your prescription at a network pharmacy or through
the plan's mail-order service
Section 2.1
To have your prescription covered, use a network pharmacy
In most cases, your prescriptions are covered only if they are filled at the plan's network
pharmacies. (See Section 2.5 for information about when we would cover prescriptions filled at
out-of-netwot•k pharmacies.)
A network pharmacy is a pharmacy that has a contract with the plan to provide your covered
prescription drugs. The term "covered drugs" means all of the Part D prescription drugs that are
covered on the plan's Drug List.
Section 2.2 Finding network pharmacies
How do you find a network pharmacy in your area?
To find a network pharmacy, you can look in your Provider Dir�ectory, visit our website
(http://www.aetnaretireeplans.com), or call Member Services (phone numbers are printed on the
back cover of this booklet). Choose whatever is easiest for you.
You may go to any of our network pharmacies. If you switch fi•om one network pharmacy to
another, and you need a refill of a drug you have been taking, you can ask either to have a new
prescription written by a provider or to have your prescription transferred to your new network
pharmacy.
What if the pharmacy you have been using leaves the network?
If the pharrnacy you have been using leaves the plan's network, you will have to find a new
pharmacy that is in the network. To find another network pharmacy in your area, you can get
help fi�om Member Services (phone nurnbeis are printed on the back cover of this booklet) or use
the Providey� Director�v. You can also find information on our website at
http://www.aetnaretireeplans. com.
What if you need a specialized pharmacy?
Sometimes prescriptions must be filled at a specialized pharmacy. Specialized pharmacies
include:
• Pharmacies that supply drugs for home infusion therapy.
GRP_12 220_A 52
HMO EOGwith RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 5: Using the plan's coverage for your Part D prescription dt�ugs
• Pharmacies that supply drugs for residents of a long-term care facility. Usually, a long-
term care facility (such as a nursing home) has its own pharmacy. Residents may get
prescription drugs through the facility's pharmacy as long as it is part of our networlc. If
your long-term care pharmacy is not in our network, please contact Member Services.
• Pharmacies that serve the Indian Health Service / Tribal / Urban Indian Health Program
(not available in Puerto Rico). Except in emergencies, only Native Americans or Alaska
Natives have access to these pharmacies in our network
• Pharmacies that dispense drugs that are restricted by the FDA to certain locations or that
require special handling, provider coordination, or education on their use. (Note: This
scenario should happen rarely.)
To locate a specialized pharmacy, look in your Provider Directory or call Member Seivices
(phone numbers are printed on the back cover of this booklet).
Section 2.3
Using the plan's mail-order services
For certain kinds of drugs, you can use the plan's network mail-order services. Generally, the
drugs available through mail order are drugs that you take on a regular basis, for a chronic or
long-term medical condition. The drugs available through our plan's mail-order service are
marked as "mail-order" drugs in our Drug List.
Our plan's mail-order seivice allows you to order up to a 90-day supply.
To get order foims and information about filling your prescriptions by mail fi•om our preferred
mail-ordet• pharmacy, contact Member Services (phone numbers are printed on the back cover of
this booklet). If you use a mail-order pharmacy not in the plan's network, your prescription will
not be covered.
Usually a mail-order pharmacy order will get to you in no more than 7 to 10 days. In the unlikely
event that there is a significant delay with your mail-order presct�iption drug, our mail order
service will work with you and a netwot•k pharmacy to provide you with a temporary supply of
your mail-order prescription drug.
Section 2.4 How can you get a long-term supply of drugs?
When you get a long-term supply of drugs, your cost sharing may be lower. The plan offers two
ways to get a long-term supply of "mail-ordef•" drugs on our plan's Drug List. (Mail-order drugs
are drugs that you take on a regular basis, for• a chronic or long-term medical condition.)
1. Some retail pharmacies in our network allow you to get a long-term supply of
maintenance drugs. Sotne of these retail pharmacies may agree to accept a lower cost-
sharing amount for a long-term supply of mail-order drugs. Your Provider Directory tells
you which pharmacies in our network can give you a long-term supply of mail-ot•der
GRP 12 220 A 53 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 5: Using the plan's coverage for your Part D prescription drugs
drugs. You can also call Member Services for mor�e� information �(phone numbers are
printed on the back cover of this booklet).
2. For certain kinds of drugs, you can use the plan's network mail-order services. The
drugs available through our plan's mail-order service at�e marked as "mail-order" drugs
in our Drug List. Our plan's mail-order service allows you to order up to a 90-day supply.
See Section 23 for more information about using our mail-order services.
Section 2.5 When can you use a pharmacy that is not in the plan's network?
Your prescription may be covered in certain situations
We have network phar•macies outside of our service area where you can get your prescriptions
filled as a member of our plan. Generally, we cover drugs filled at an out-of-network pharmacy
only when you are not able to use a network pharmacy. Here are the cu•cumstances when we
would cover prescriptions filled at an out-of-network pharmacy:
• If you are unable to obtain a covered prescription drug in a timely manner within our
seivice area because there is no network pharmacy within a reasonable driving distance
that provides 24 hour service.
• If you are ttying to fill a pr•escription drug that is not regularly stocked at an accessible
network retail or mail order pharmacy (these prescr�iption drugs include orphan drugs or
other specialty pharmaceuticals).
• If you are traveling outside your service a1�ea (within the United States) and t�un out of
your medication, if you lose your medication, or if you become ill and cannot access a
network pharmacy.
• If you receive a Part D prescription drug, dispensed by an out-of-network institutional-
based pharmacy, while you are in the emergency department, pt•ovider-based clinic,
outpatient sur•geiy or other outpatient setting.
• If you have not received your prescription during a state or federal disaster declaration or
othet• public health emei•gency declaration in which you are evacuated or otherwise
displaced fi�om your service area or place ofresidence.
In these situations when you are covered to fill your prescription at an out-of-network pharmacy,
you rnay be limited to a 31-day supply ofyour drug.
In these situations, piease check first with Member Services to see if there is a network
pharrnacy nearby. (Phone numbers for Mernber Services are printed on the back cover of this
booklet.)
How do you aslc for reimbursement from the plan?
If you rnust use an out-of-network pharmacy, you will generally have to pay the full cost (rather
than your nornlal shat�e of the cost) when you fill your prescription. You can ask us to reimburse
GRP_12 220 A 54 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for� Aetna MedicareSM Plan (HMO)
Chapter 5: Using the plan's coverage for your Part D prescription drugs
you for our share of the cost. (Chapter 7, Section 2.1 explains how to ask the plan to pay you
back.)
SECTION 3
Section 3.1
Your drugs need to be on the plan's "Drug List"
The "Drug List" tells which Part D drugs are covered
The plan has a"List of Covered Drugs (Formztlary). " In this Evidence of Coverage, we call it
the "Drug List" for short.
The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists.
The list must meet requirements set by Medicare. Medicare has approved the plan's Drug List.
The drugs on the Drug List are only those covered under Medicare Part D(earlier in this chapter,
Section l.l explains about Part D drugs).
We will generally cover a drug on the plan's Drug List as long as you follow the other coverage
rules explained in this chapter and use of the drug is a medically accepted indication. A
"medically accepted indication" is a use of the drug that is either:
• approved by the Food and Dt�ug Administration. (That is, the Food and Drug
Administration has approved the drug for the diagnosis or condition for which it is being
prescribed.)
• -- or -- supported by certain reference books. (These reference books at•e the American
Hospital Formulary Service Drug Information, the DRUGDEX Information System, and
the USPDI or its successor.)
The Drug List includes both brand name and generic drugs
A genef•ic drug is a prescription drug that has the same active ingredients as the brand name dr�ug.
Generally, it works just as well as the brand name drug and usually costs less. There are gener•ic
drug substitutes available for many brand name drugs.
What is not on the Drug List?
The plan does not cover all prescription drugs.
• In some cases, the law does not allow any Medicare plan to cover cet�tain types of drugs
(for more about this, see Section 7.1 in this chapter•).
• In other cases, we have decided not to include a particular drug on our Drug List.
Section 3.2 There are different "cost-sharing tiers" for drugs on the Drug List
Eveiy drug on the plan's Drug List is in a cost-sharing tier. In genet•al, the higher the cost-
shat•ing tiet•, the higher your cost for the drug.
The tier structure for your plan and the amount you pay fot• covered prescription drugs is outlined
in the Prescription Drug Benefits Chart (also referred to as the Aetna Schedule of Copayments/
GRP 12 220 A 55 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 5: Using the plan's coverage for your Part D prescription drugs
Coinsurance) included with this Evidence of Coverage. Your tier structure will be one of the
following:
��
Two Tier Plan
Tier 1 generic dr�ugs
Tiet� 2 brand drugs
��
.
Three Tier Plan
Tier 1 generic drugs
Tier 2 preferred brand
drugs
Tier 3 non-preferred
brand dr�ugs
Four Tier Plan
• Tier 1 pr•eferred
generic drugs
• Tier 2 non-preferred
generic drugs
• Tier 3 preferred brand
drugs
• Tier 4 non-prefet•red
brand drugs
Four Tier Plan
• Tier 1 generic drugs
• Tier 2 prefer•red brand drugs
• Tier 3 non-preferred brand drugs
• Tier 4 specialty tier drugs
Five Tier Plan
• Tier 1 preferred generic drugs
• Tier 2 non-preferred generic drugs
• Tier 3 preferred brand drugs
• Tier 4 non-preferred brand drugs
• Tier 5 specialty tier drugs
To find out which cost-sharing tier your drug is in, look it up in the plan's Drug List.
The amount you pay for drugs in each cost-sharing tier is shown in the Prescription Drug
Benefits Chart (also refert•ed to as the Aetna Schedule of Copayments/Coinsurance) included
with this Evidence of Coverage.
Section 3.3
How can you iind out if a specific drug is on the Drug List?
You have three ways to find out:
1. Check the most t�ecent Drug List we sent you in the mail. (Please note: The Dt•ug List we
send includes infor•mation for the covered drugs that are most commonly used by our
membet•s. However, we cover additional drugs that are not iucluded in the printed Drug
List. If one of your drugs is not listed in the Drug List, you should visit our website or
contact Members Services to find out if we cover it.)
2.
Visit the plan's website at http://www.aetnaretireeplans.com. The Drug List on the
website is always the most current.
3. Call Member Services to find out if a particular drug is on the plan's Drug List or to ask
for a copy of the list. (Phone numbers for Member Services are printed on the back cover
of this booklet.)
GRP_i2 220 A 56 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 5: Using the plan's coverage for your Part D prescription drugs
SECTION 4
Section 4.1
There are restrictions on coverage for some drugs
Why do some drugs have restrictions?
For certain prescription drugs, special rules restrict how and when the plan covers them. A team
of doctors and pharmacists developed these rules to help our members use drugs in the most
effective ways. These special rules also help control overall drug costs, which keeps your drug
coverage more affordable.
In general, our rules encourage you to get a drug that works for your medical condition and is
safe and effective. Whenever a safe, lower-cost drug will work medically just as well as a higher-
cost drug, the plan's rules are designed to encourage you and your provider to use that lower-cost
option. We also need to comply with Medicare's rules and regulations for drug coverage and cost
sharing.
If there is a restriction for your drug, it usually means that you or your provider will have
to take extra steps in order for us to cover the drug. If you want us to waive the restriction for
you, you will need to use the formal appeals process and ask us to make an exception. We may
or may not agree to waive the restriction for you. (See Chapter 9, Section 6.2 for information
about asking for exceptions.)
Section 4.2 What kinds of restrictions?
Our plan uses different types of restrictions to help our members use drugs in the most effective
ways. The sections below tell you more about the types of restrictions we use for certain drugs.
Restricting brand name drugs when a generic version is available
Generally, a"generic" drug works the same as a brand name drug and usually costs less. When a
generic version of a brand name drug is available, our network pharmacies will provide
you the generic version. We usually will not cover the brand name drug when a generic version
is available. However, if your provider has told us the medical reason that the generic drug wiil
not work for you then we will cover the brand name drug. (Your share of the cost may be greater
for the brand name drug than for the generic drug.)
Getting plan approval in advance
For certain drugs, you or your provider need to get approval from the plan before we will agree
to cover the drug for you. This is caiied "prior authorization." Sometimes the requirement for
getting approval in advance helps guide appropriate use of certain drugs. If you do not get this
approval, your drug might not be covered by the plan.
Trying a different drug first
This requirement encour�ages you to try less costly but just as effective drugs before the plan covers
another drug. For example, if Drug A and Drug B treat the same medical condition, the plan inay
requi�•e you to tiy Drug A first. If Drug A does not work for you, the plan will then cover Drug
B. This requirement to tly a different drug first is called "step therapy."
GRP 12 220 A 57 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 5: Using the plan's coverage for your Pat•t D prescription drugs
Quantity limits
For• certain drugs, we limit the amount of the drug that you can have. For example, the plan
might limit how many refills you can get, or how much of a dr•ug you can get each time you fill
your prescription. For exampie, if it is norrnally considered safe to take only one pill per day for
a certain drug, we may litnit coverage for your prescription to no inore than one pill per day.
Section 4.3
Do any of these restrictions apply to your drugs?
The plan's Drug List includes inforination about the restr•ictions described above. To find out if
any of these restr•ictions apply to a drug you take or want to take, check the Drug List. For the
most up-to-date information, call Member Services (phone numbers are printed on the back
cover of this booklet) or check our website (http://www.aetnaretireeplans.com).
If there is a restriction for your drug, it usually means that you or your provider will have
to take extra steps in order for us to cover the drug. If there is a restriction on the drug you
want to take, you should contact Member Services to learn what you or your provider would
need to do to get coverage for the drug. If you want us to waive the restriction for you, you will
need to use the formal appeals process and ask us to make an exception. We may or may not
agree to waive the restriction for you. (See Chapter 9, Section 6.2 for� information about asking
for exceptions.)
SECTION 5
Section 5.1
What if one of your drugs is not covered in the way you'd
like it to be covered?
There are things you can do if your drug is not covered in the way
you'd like it to be covered
Suppose there is a prescription drug you are currently taking, or one that you and your provider
think you should be taking. We hope that your drug coverage will work well for you, but it's
possible that you might have a problem. For• example:
• What if the drug you want to take is uot covered by the plan? For example, the drug
might not be covered at all. Or� maybe a generic vet•sion of the drug is covered but the
brand name version you want to take is not covered.
• What if the drug is covered, but there are extra rules or restrictions on coverage for
that drug? As explained in Section 4, some of the dr•ugs covered by the plan have extra
rules to t�estrict their use. For example, you might be requu�ed to try a differ•ent drug first,
to see if it will work, before the drug you want to take will be covered for you. Or there
might be litnits on what ainount of the drug (number of pilis, etc.) is covered during a
particular time period. In some cases, you tnay want us to waive the restriction for you.
For example, you might want us to cover• a certain drug for you without having to tt•y
other drugs fu•st. Or you may want us to cover more of a drug (number of pills, etc.) than
we normally will cover.
GRP_12 220 A 58 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 5: Using the plan's coverage for your Part D prescription dr�ugs
• What if the drug is covered, but it is in a cost-sharing tier that makes your cost
sharing more expensive than you think it should be? The plan puts each covered dr•ug
into one of a number of different cost-sharing tiers. How much you pay for your
prescription depends in part on which cost-sharing tier your drug is in.
There are things you can do if your drug is not covered in the way that you'd like it to be
covered. Your options depend on what type of problem you have:
• If your drug is not on the Drug List or if your drug is restricted, go to Section 5.2 to learn
what you can do.
If your drug is in a cost-sharing tier that makes your cost more expensive than you think
it should be, go to Section 5.3 to learn what you can do.
Section 5.2
What can you do if your drug is not on the Drug List or if the drug is
restricted in some way?
If your drug is not on the Drug List or is restricted, here are things you can do:
• You may be able to get a temporary supply of the drug (only members in certain
situations can get a temporary supply). This will give you and your provider time to
change to another drug or to iile a request to have the dt•ug covered.
• You can change to another drug.
• You can request an exception and ask the plan to covet• the drug or remove restrictions
from the drug.
You may be able to get a temporary supply
Under certain circumstances, the plan can offer a tempor•aty supply of a drug to you when your
drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to
talk with your provider about the change in covet�age and iigure out what to do.
To be eligible for a temporary supply, you must meet the two requn•ements below:
1. The change to your drug coverage must be one of the following types of changes:
• The drug you have been taking is no longer on the plan's Drug List.
• -- or -- the drug you have been taking is now restricted in some way (Section 4
in this chapter tells about restrictions).
2. You must be in one of the situations described below:
• For those members who were in the plan last year and aren't in a long-term
care faciliiy:
We will cover a temporaty supply of your drug one time only during the �irst 90
days of the calendar year. This temporary supply will be for a maximum of a
31-day supply, or less if your prescription is written for fewer days. The
prescription must be filled at a network pharmacy.
GRP_12 220 A 59 HMO EOC-with 1ZY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 5: Using the plan's coverage fot• your Part D prescription drugs
• For those members who are new to the plan and aren't in a long-term care
facility:
We will cover a temporary supply of your drug one time only during the first 90
days of your membership in the plan. This temporary supply will be for a
maximum of a 31-day supply, or less if your prescription is written for fewer
days. The prescription must be filled at a network phai7nacy.
• For those members who are new to the plan and reside in a long-term care
facility:
We will cover a temporaty supply of your drug during the �rst 90 days of your
membership in the plan. The fn�st supply will be for a maximum of 31-day
supply, or less if your prescription is written for fewer days. If needed, we will
cover additional refills dut�ing your first 90 days in the plan.
• For those members who have been in the plan for more than 90 days and
reside in a long-term care facility and need a supply right away:
We will cover one 31-day supply, or less if your prescription is written for fewer•
days. This is in addition to the above long-term care transition supply.
• Current members with a level of care changes:
If outside a transition of coverage period (at any tim
membets will receive up to a 31-day prescription
experience a change in their level of care.
e during the year), current
transition fill when they
To ask for a temporaty supply, call Member Services (phone numbers are printed on the back
cover of this booklet).
During the time when you are getting a ternporary supply of a drug, you should talk with your
provider to decide what to do when your temporat•y supply t�uns out. You can eithet� switch to a
different drug covered by the plan or aslc the plan to make an exception for you and cover your
current drug. The sections below tell you more about these options.
You can change to another drug
Start by talking with your provider. Perhaps there is a different dtug covered by the plan that
rnight work just as well for you. You can call Member Setvices to ask for a list of covered drugs
that treat the same medical condition. This list can help your provider fmd a covered drug that
might work for you. (Phone numbers for Member Services are printed on the back cover of this
booklet.)
You can ask for an exception
You and your provider can ask the plan to make an exception for you and cover the drug in the
way you would like it to be covered. If your provider says that you have medical reasons that
justify asking us for an exception, your provider can help you request an exception to the rule.
For example, you can ask the plan to cover a drug even though it is not on the plan's Dtug List.
Or you can ask the plan to make an exception and covet• the dt�ug without t�estrictions.
GRP_12 220 A 60 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 5: Using the plan's coverage for your Part D prescription drugs
If you and your provider want to ask for an exception, Chapter 9, Section 6.4 tells what to do. It
explains the procedures and deadlines that have been set by Medicare to rnake sure your request
is handled promptly and fairly.
Section 5.3
What can you do if your drug is in a cost-sharing tier you think is too
high?
If your drug is in a cost-sharing tiet� you think is too high, here are things you can do:
You can change to another drug
If your drug is in a cost-sharing tier you think is too high, start by talking with your pr�ovider.
Perhaps there is a different drug in a lower cost-sharing tier that might work just as well for you.
You can call Member Services to ask for a list of covered drugs that treat the same medical
condition. This list can help your provider find a covered drug that might work for you. (Phone
numbeis for Member Services are printed on the back cover of this booklet.)
You can ask for an exception
If your plan's tier structure has non-preferred cost-sharing tiers, you and your provider can ask
the plan to make an exception in the cost-sharing tier for the drug so that you pay less for it. If
your provider says that you have medical reasons that justify asking us for an exception, your
provider can help you request an exception to the rule.
If you and your provider want to ask for an exception, Chapter 9, Section 6.4 tells what to do. It
explains the procedures and deadlines that have been set by Medicare to make sure your request
is handled promptly and fairly.
Drugs in some of our cost-sharing tiers are not eligible for this type of exception. VVe do not
lower the cost-sharing amount for drugs in the Specialty tier.
SECTION 6
Section 6.1
What if your coverage changes for one of your drugs?
The Drug List can change during the year
Most of the changes in drug coverage happen at the beginning of each year (January 1).
However, dut�ing the year, the plan might make many kinds of changes to the Drug List. For
example, the pian might:
• Add or remove cirugs from the Dl•ug List. New drugs become available, including new
generic drugs. Perhaps the government has given appt•oval to a new use for an existing
drug. Sometimes, a drug gets recalled and we decide not to cover it. Or we might remove
a drug from the list because it has been found to be ineffective.
��
Move a drug to a higher or lower cost-sharing tier.
Add or remove a restriction on coverage for a
restrictions to coverage, see Section 4 in this chapter).
drug (for more information about
GRP 12 220 A 61 HMO EOGwith RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (IIMO)
Chapter 5: Using the plan's coverage for your Part D prescription drugs
• Replace a brand name drug with a generic drug.
In almost all cases, we must get approval fi•om Medicare for changes we make to the plan's Drug
List.
Sectiou 6.2
What happeus if coverage chauges for a drug you are taking?
How will you iind out if your drug's coverage has been changed?
If thet�e is a change to coverage for a dr�ug you are taking, the plan will send you a notice to tell
you. Normally, we will let you know at least 60 days ahead of time.
Once in a while, a drug is suddenly recailed because it's been found to be unsafe or for other
reasons. Ifthis happens, the plan will immediately remove the drug from the Drug List. We will
let you know of this change right away. Your provider will also know about this change, and can
work with you to find another drug for your condition.
Do changes to your drug coverage affect you right away?
If any of the following types of changes affect a dt•ug you are taking,
you until January 1 of the next year if you stay in the plan:
• If we move your drug into a higher cost-shai�ing tier.
If we put a new restriction on your use of the dt•ug.
the change will not affect
If we remove your drug from the Drug Llst, but not because of a sudden recall or because
a new generic drug has replaced it.
If any of these changes happens for a dt•ug you are taking, then the change won't affect your use
or what you pay as your share of the cost until Januat•y 1 of the next year. Until that date, you
probably won't see any increase in your payments or any added restriction to your use of the
drug. However, on Januaty 1 ofthe next year, the changes will affect you.
In some cases, you will be affected by the coverage cl�ange before January 1:
• If a brand name drug you are taking is replacecl by a new generic drug, the plan must
give you at least 60 days' notice or give you a 60-day reiill of your brand name drug at a
networlc pharmacy.
• During this 60-day period, you should be working with your provider to switch to
the generic or to a different drug that we cover.
• Or you and your provider can ask the plan to make an exception and continue to
cover the bt�and name drug for you. For infortnation on how to ask for an
exception, see Chapter 9(What to do if you have a�r�oblefn ol• compinint
(cover�crge decisions, appeals, complaints)).
• Again, if a drug is suddeuly recalled because it's been found to be unsafe or for other
reasons, the plan will immediately relnove the drug fi•om tlie Drug List. We will let you
know of this change right away.
GRP_12 220 A 62 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 5: Using the plan's coverage for your Part D prescription drugs
• Your provider will also know about this change, and can wor•k with you to find
another drug for your condition.
SECTION 7
Section 7.1
What types of drugs are not covered by the plan?
Types of drugs we do not cover
This section tells you what kinds of prescription drugs are "excluded." This means Medicare
does not pay for these drugs.
If you get drugs that are excluded, you must pay for them yourself. We won't pay for the dt•ugs
that are listed in this section.* (The only exception: Ifthe requested drug is found upon appeal to
be a drug that is not excluded under Part D and we should have paid for or covered it because of
your specific situation. (For• information about appealing a decision we have made to not cover a
drug, go to Chapter 9, Section 6.5 in this booklet.)
Here are three general rules about drugs that Medicare drug plans will not cover under Part D:
• Our plan's Part D drug coverage cannot cover a drug that would be covered under
Medicare Part A or Part B.
• Our plan cannot cover a drug purchased outside the United States and its terr•itories.
• Our plan usually cannot cover off-label use. "Off-label use" is any use of the drug other
than those indicated on a drug's label as appt•oved by the Food and Drug Administration.
• Generally, coverage for "off-label use" is allowed only when the use is supported
by certain reference books. These reference books are the American Hospital
Formulary Service Drug Information, the DRUGDEX Information System, and
the USPDI or its successor. If the use is not supported by any of these reference
books, then our plan cannot cover its "off-label use."
Also, by law, these categories of dr•ugs are not covered by Medicar•e drug plans:
• Non-prescription drugs (also called over-the-counter drugs)
• Drugs when used to promote fertility
• Drugs when used for the relief of cough or cold symptoms
• Drugs when used for cosmetic puiposes or to promote hair growth
• Prescription
preparations
vitamins and mineral products, except prenatal vitamins and fluor•ide
• Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra,
Cialis, Levitra, and Caverject
• Drugs when used for treatment of anorexia, weight loss, or weight gain
GRP 12 220 A 63 HN10 EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 5: Using the plan's coverage for your Part D prescription dt•ugs
• Outpatient drugs for which the manufacturet� seeks to r•equire that associated tests or
tnonitoring services be purchased exclusively from the tnanufacturer as a condition of
sale
• Barbiturates, except when used to treat epilepsy, cancer, or a chronic mental health
disorder•
*Your former employer/union/trust may offer additional coverage of some prescription drugs not
normally covered in a Medicare prescription drug plan. If included, this will be identified on
page 1 of your Prescription Drug Benefits Chart (Schedule of Copayments/Coinsurance) under
the section "Enhanced Drug Benefit." The amount you �ay when you iill a prescription for these
drugs does not count toward qualifying you for the Catastrophic Coverage Stage.
In addition, if you are receiving Extra Help from Medicare to pay for your prescriptions, the
Extt�a Help program will not pay for the drugs not normally covered. (Please refer to your
formulaiy or call Member Services for more information.) However, if you have drug coverage
thz•ough Medicaid, your state Medicaid program may cover some prescription drugs not normally
covered in a Medicare drug plan. Please contact your state Medicaid program to determine what
drug coverage may be a�ailable to you. (You can find phone numbers and contact information
fot• Medicaid in Addendum A at the end of this booklet.)
SECTION 8 Show your plan membership card when you fill a
prescription
Section 8.1
Show your membership card
To fill your prescription, show your plan membership card at the network pharmacy you choose.
When you show your plan membership card, the network pharmacy will automatically bill the
plan for oari• share of your covered prescription drug cost. You will need to pay the pharmacy
yoz�r• share of the cost when you pick up your• prescription.
Section 8.2 What if you don't have your membership card with you?
If you don't have your plan membership card with you when you fill your prescription, ask the
pharmacy to call the plan to get the necessaiy infortnation.
If the pharmacy is not able to get the necessary information, you may have to pay the full cost
of the prescription when you pick it up. (You can then ask us to reimburse you foi• our share.
See Chapter 7, Section 2.1 for information about how to ask the plan for reimbursement.)
GRP_12 220 A 64 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
` Chapter 5: Using the plan's coverage for• your Part D prescription drugs
SECTION 9 Part D drug coverage in special situations
Section 9.1 What if you're in a hospital or a skilled nursing facility for a stay that
is covered by the plan?
If you are admitted to a hospital or to a skilled nursing facility for a stay covered by the plan, we
will generally cover the cost of your prescription dtugs during your stay. Once you leave the
hospital or skilled nursing facility, the plan will cover your drugs as long as the drugs meet all of
our rules for coverage. See the previous parts of this section that tell about the rules for getting
drug coverage. Chapter 6(What you pay for yozcr Part D prescrzption d��zcgs) gives more
information about drug coverage and what you pay.
Please Note: When you enter, live in, or leave a skilled nursing facility, you are entitled to a
special enrollment period. During this time period, you can switch plans or change your
coverage. (Chapter 10, Ending your f�aembeNship in the plan, tells when you can leave our plan
and join a different Medicare plan.)
Section 9.2 What if you're a resident in a long-term care facility?
Usually, a long-term care facility (such as a nursing home) has its own pharmacy, or a pharmacy
that supplies drugs for all of its residents. If you are a resident of a long-term cat�e facility, you
may get your prescription drugs through the facility's pharmacy as long as it is part of our
network.
Check your Provider Dif•ectory to find out if your long-tei•m care facility's pharmacy is part of
our network. If it isn't, or if you need more information, please contact Member Services (phone
numbers are printed on the bacic cover of this booklet).
What if you're a resident in a long-term care facility and become a new member of the
plan?
If you need a drug that is not on our Drug List or is restricted in some way, the plan will cover a
temporary supply of your drug during the fu•st 90 days of your membership. The first supply will
be for a maximum of a 31-day supply, ot• less if your prescription is written for fewer days. If
needed, we will cover additional refills during your first 90 days in the plan.
If you have been a member of the plan for more than 90 days and need a drug that is not on our
Drug List or if the plan has any restriction on the drug's coverage, we will cover one 31-day
supply, or less if your prescription is written for fewer days.
During the time when you are getting a temporary supply of a drug, you should talk with your
provider to decide what to do when your temporary supply runs out. Perhaps there is a different
drug covered by the plan that might work just as well for you. Or you and your provider can ask
the plan to malce an exception for you and cover the drug in the way you would lilce it to be
covered. If you and your provider want to ask for an exception, Chapter 9, Section 6.4 tells what
to do.
GRP 12 220 A 65 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 5: Using the plan's coverage for your Par�t D prescription drugs
Section 9.3 What if you're also getting drug coverage from another
employer/union/trust retiree group plan?
Do you currently have other prescription drug coverage through your (or your spouse's)
employer or t•eti��ee group? If so, please contact that group's benefits administrator. He or she
can help you deterinine how your cut•rent prescription drug coverage will wor•k with our plan.
In general, if you are cut•rently employed, the prescription drug coverage you get from us will be
secondary to your employer or retiree gt•oup coverage. That means your group coverage would
pay first.
Special note about `creditable coverage':
If you are covered by another ernployer/union/trust retiree group plan, each year that employer or
retu•ee gt�oup should send you a notice that tells if yout• prescription drug coverage for the next
calendar year is "ct•editable" and the choices you have for drug coverage for the next calendat•
year is "creditable".
If the coverage from the group plan is "creditable," it means that the plan has drug coverage that
is expected to pay, on average, at least as much as Medicare's standard prescription dt•ug
coverage.
Keep these notices about creditable coverage, because you may need them later. If you enroll
in a Medicare plan that includes Part D drug coverage, you may need these notices to show that
you have maintained creditable coverage. If you didn't get a notice about creditable coverage
from your employer or retiree group plan, you can get a copy from the employer or retiree
group's benefits administrator or the employer oz� union.
SECTION 10
Section 10.1
Programs on drug safety and managing medications
Programs to help members use drugs safely
We conduct drug use reviews for our members to help make sure that they ar�e getting safe and
appropriate cat•e. These reviews are especially important for• members who have tnore than one
provider who prescr�ibes their drugs.
We do a review each time you fill a prescription. We also review our records on a regular basis.
During these reviews, we look for potential problems such as:
• Possible medication errors
• Drugs that may not be necessary because you are taking another drug to treat the same
medical condition
• Drugs that may not be safe or appropriate because of your age or gender
• Certain combinations of drugs that could harm you if taken at the same time
• Prescriptions wr•itten for drugs that have ingredients you at�e allergic to
• Possible ert�ors in the amount (dosage) of a drug you are taking.
GRP_12 220 A 66 HMO EOC-with Rx (Y2013)
2013 Evidence of Cover�age for Aetna MedicareSM Plan (HMO)
Chapter 5: Using the plan's coverage for your Part D prescription drugs
If we see a possible problem in your use of inedications, we will work with your provider to
correct the problem.
Section 10.2 Programs to help members manage their medications
We have programs that can help our members with special situations. For example, some
members have several complex medical conditions or they may need to take many drugs at the
same time, or they could have very high drug costs.
These programs are voluntary and free to members. A team of phar•macists and doctors
developed the programs for us. The programs can help make sure that our members are using the
drugs that work best to treat then• medical conditions and help us identify possible medication
errois.
If we have a program that fits your needs, we will automatically enroll you in the program and
send you information. If you decide not to pat�ticipate, please notify us and we will withdraw you
from the program. If you have any questions about these programs, please contact Member
Services (phone numbers are printed on the back cover of this booklet).
GRP 12 220 A 67 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 6: What you pay for your Part D prescription drugs
Chapter 6. What you pav for your Part D prescription dru�s
SECTION 1 Introduction
Section 1.1
Use this chapter together with othet• materials that explain your
dt�ug coverage
SECTION 2 What you pay for a drug depends on which "drug payment stage" you are in
when you get the drug
Section 2.1 What are the drug payment stages for our plan members?
SECTION 3 We send you reports that explain payments for your drugs aud which
payment stage you are in
Section 3.1 We send you a monthly report called the "Explanation of Benefits"
(the "EOB")
Section 3.2 Help us keep our information about your drug payments up to date
SECTION 4 During the Deductible Stage (if applicable), you pay the full cost of your Part
D drugs
Section 4.1
You stay in the Deductible Stage until you have paid any
applicable cost sharing for your Part D drugs
SECTION 5 During the Initial Coverage Stage, the plan pays its share of your drug costs
and you pay your share
Section 5.1 What you pay for a drug depends on the drug and where you fill
your prescription
Section 5.2 Refer to your Prescription Drug Benefits Chart for a table that
Section 5.3
Section 5.4
shows your costs for a one-month supply of a dtug
Refer to your Prescription Drug Benefits Chart for a table that
shows your• costs for a long-term (up to a 90-day) supply of a drug
You stay in the Initial Coverage Stage until your total drug costs
for the year reach the initial coverage limit
SECTION 6 During the Coverage Gap Stage, our plan may provide some coverage, or
you receive a discount on brand uame drugs and pay no more than 79% of
the costs for generic drugs
Section 6.1 You stay in the Coverage Gap Stage until your out-of-pocket costs
reach $4,750
Section 6.2
How Medicat�e calculates your out-of-pocket costs for prescription
drugs
SECTION 7 During the Catastrophic Coverage Stage, the plan pays most of the cost for
yourdrugs
Section 7.1 Once you are in the Catastrophic Coverage Stage, you will stay in
this stage for the rest of the year
GRP_l2 220 A 68 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 6: What you pay for your Part D presct•iption drugs
SECTION S What you pay for vaccinations covered by Part D depends on how and where
you get them
Section 8.1 Our plan has separate coverage for the Part D vaccine medication
itself and for the cost of giving you the vaccination shot
Section 8.2 You may want to call us at Member Services before you get a
vaccination
SECTION 9 Do you have to pay the Part D"late enrollment penalty"?
Section 9.1 What is the Part D"late enrollment penalty"?
Section 9.2 How much is the Part D late enrollment penalty?
Section 93 In some situations, you can enroll late and not have to pay the
Section 9.4
penalty
What can you do if you disagree about your late enrollment
penalty?
SECTION 10 Do you have to pay an extra Part D amount because of your income?
Section 10.1 Who pays an extra Part D amount because of income?
Section 10.2 How much is the extra Part D amount?
Section 10.3 What can you do if you disagree about paying an extra Part D
amount?
Section 10.4 What happens if you do not pay the extra Part D amount?
GRP 12 220 A 69 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 6: What you pay for your Part D prescription drugs
Did you know there are programs to help people pay for their drugs?
There are programs to help people with limited resources pay for their drugs.
These include "Extt�a Help" and State Pharmaceutical Assistance Programs.
For more information, see Chapter 2, Section 7.
Are you currently getting help to pay for your drugs?
If you are in a program that helps pay for your drugs, some information in
this Evidetace of Coverage about the costs for Part D prescription drugs
may not apply to you. We send you a separate insert, called the `Bvidence of
Coverage Rider for People Who Get Extr�a Help Paying for Prescription
Drugs" (also known as the "Low Income Subsidy Rider" or the "LIS Rider"),
which tells you about your drug coverage. If you don't have this insert, please
call Member Services and ask for the "LIS Rider." (Phone numbers for
Membet• Services are printed on the back cover of this booklet.)
SECTION 1
Section l.l
Introduction
Use this chapter together with other materials that explain your drug
coverage
This chapter focuses on what you pay for your Part D prescription drugs. To keep things simple,
we use "drug" in this chapter to mean a Part D prescription drug. As explained in Chapter 5, not
all drugs are Part D dt•ugs — some drugs are covered under Medicare Part A or Pat�t B and other
dr•ugs are excluded fi�om Medicare covet•age by law. (Some excluded drugs may be covered by
our plan if your former employer/union/trust has purchased an Enhanced Drug Benefit.)
To understand the paytnent information we give you in this chapter, you need to know the basics
of what drugs are covered, where to fill your prescriptions, and what rules to follow when you
get your covered drugs. Here are materials that explain these basics:
• The plan's List of Covef•ed Drugs (Fot•marlury). To keep things simple, we call this the
"Drug List."
• This Drug List tells which drugs are covered for you.
��
It also tells which of the plan's "cost-sharing tiers" the drug is in and whether
there are any restrictions on yout• coverage for the drug.
• If you need a copy of the Drug List, call Member Seivices (phone numbers are
printed on the back cover of this booklet). You can also find the Drug List on our
website at: http://www.aetnaretireeplans.com. The Drug List on the website is
always the most current.
• Chapter 5 of this booklet. Chapter 5 gives the details about your prescription drug
coverage, including rules you need to follow when you get your covered drugs. Chapter 5
also tells which types of prescription drugs are not covered by our plan.
GRP_12 220 A 70 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna Medicai•eSM Plan (HMO)
Chapter 6: What you pay for your Part D prescription drugs
• The plan's P�•ovider Dif�ectory. In most situations you must use a network pharmacy to
get your covered drugs (see Chapter 5 for the details). The Provzde�• Directory has a list
of pharmacies in the plan's network It also tells you which pharmacies in our network
can give you a long-term supply of a drug (such as filling a prescription fot� a three-
month's supply).
SECTION 2 What you pay for a drug depends on which "drug payment
stage" you are in when you get the drug
Section 2.1
What are the drug payment stages for our plan members?
As shown in the table below, there are "drug payment stages" for your prescription drug
coverage under our plan. How much you pay for a drug depends on which of these stages you
are in at the time you get a prescription filled or refilled. Keep in mind you are always
responsible for the plan's monthly premium (if applicable) regardless of the drug payment stage.
GRP 12 220 A 71 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage fot� Aetna MedicareSM Plan (HMO)
Chaptei• 6: What you pay for yout• Part D prescription drugs
�� Stage 1 � Stage 2 �' Stage 3 � Stage 4 �
� �
� Yearly Declucttble � Intttal Coverage � Covey�age Gap Stage � Ccrtastrophic �
� Stctge � Stage � Covef age Stage
�.-.:. . ....� ._:..� �...�� � �..r ����� . �„ � w. ..,�x � � � .. � � �._ t��
�„ . .. _ . �.
The amounts you pay during these stages is listed in the Prescription Drug Bene�its Chart� �
� (Schedule of Co�ayments/ Coinsurance) included wrth this Evrdetzce of Coveruge �
��v..��
� If your plan has a$���4rt � After you (or others � During this stage, you � During this stage, the �
� deductible, during this ; on your behal� have ` will pay 47.5% ofthe � plan will pay most of �
� stage you pay the full � met your plan � price (plus the � the cost of your drugs �
� cost of your drugs. ; deductible (if �� dispensing fee) for � for the rest of the ��
� � applicable), the plan � brand name drugs and �� calendar year (through �
, You stay ui this stage � pays its share of the � 79% of the price for � December 31 2013). ��
� ' �
�� until you have paid � costs of your drugs �� generic drugs if youi � `
� the amount of your � and you pay your � plan does not include �(Details are in Section `��
� plan's deductible). � share. � supplemental � 7 of this chapter.) �
� � �
� .� � coverage. � �
�(Details are in Section � You stay in this stage �.
" 4 of this chapter.) � until your year-to-date r If your plan includes �� �
� "total drug costs" � supplemental �
� �(your payments plus F coverage for generic � '
� y any Part D plan's � drugs, you will pay � 4
� payments) total the � the applicable tier's �
� � amount of your inrtial ' cost sharing for these � �
� � covet�age limit. �� dt�ugs. � �
� � � �
� �(Details are in Section � If your plan includes � �
� � 5 of this chapter�.) � supplernental � ��
�
� $� � coverage for brand � �
� � drugs, you will " `
` � �� �
� � receive a discount � �
� � ,i' after the plan's benefit � ��
�; � is applied. � ��
�,
� {3 r, You stay ul this stage � �
�� � � until your year-to-date ' �
�, �
� �� � "out-of-pocket costs" � �
� , "{
�
� � f� (your payments) reach �� �
�� �' �� a total of $4,750. This � �
� ;I amount and rules fot � �
� �i counting costs toward �
� �I this amount have been � �
�
� �� set by Medicare. � �
� � `I � �
i� �' E k' 1
� � �� (Details at•e in Section �; �i
� � � 6 of this chaptei ) �� �,
,.� F. �..� � . � d � . . �- .. ..� �_
GRP_12 220 A 72 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Pian (HMO)
Chapter 6: What you pay for yout• Part D pr•escription drugs
SECTION 3 We send you reports that explain payments for your drugs
and which payment stage you are in
Section 3.1
We send you
(the "EOB")
a monthly report called the "Explanation of Bene�its"
Our plan keeps track of the costs of your prescription drugs and the payments you have made
when you get your prescriptions filled or refilled at the pharmacy. This way, we can tell you
when you have moved fi•om one drug payment stage to the next. In particular, there are two types
of costs we keep track of:
• We keep h�ack of how much you have paid. This is called your "out-of-pockeY' cost.
• We keep track of your "total drug costs." This is the amount you pay out-of-pocket or
others pay on your behalf plus the amount paid by the plan.
Our plan will prepare a written report called the Explcrnation of Benefits (it is sometimes called
the `BOB") when you have had one or more prescriptions filled through the plan during the
previous month. It includes:
• Information for that month. This report gives the payment details about the
prescriptions you have filled during the previous month. It shows the total drugs costs,
what the plan paid, and what you and others on your behalf paid.
Totals for the year since January l. This is called "year-to-date" information. It shows
you the total drug costs and total payments for your drugs since the year began.
Section 3.2
Help us keep our information about your drug payments up to date
To keep track of your drug costs and the payments you make for drugs, we use records we get
fi•om pharmacies. Here is how you can help us keep your information correct and up to date:
• Show your membership card when you get a prescription filled. To make sure we
know about the prescriptions you are filling and what you are paying, show your plan
membeiship card every time you get a prescription filled.
• Make sure we have the information we need. Thet•e are times you may pay for
prescription drugs when we will not automatically get the information we need to
keep track of your out-of-pocket costs. To help us keep track of your out-of-pocket costs,
you may give us copies of receipts for drugs that you have purchased. (If you are billed
for a covet•ed drug, you can ask our plan to pay our share of the cost. For instructions on
how to do this, go to Chapter 7, Section 2 of this booklet.) Here are some types of
situations when you may want to give us copies of your drug receipts to be sure we have
a complete record of what you have spent for your drugs:
• When you purchase a covered drug at a networlc pharmacy at a special price or
using a discount card that is not part of our plan's benefit.
When you made a copayment for drugs that are provided under a drug
manufacturer patient assistance program.
GRP 12 220 A 73 HMO EOC—with R�c (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 6: What you pay for your Part D prescription drugs
• Any time you have purchased covered drugs at out-of-network phar�macies or
other times you have paid the full price for a covered drug under special
cit�cumstances.
• Send us informatiou about the payments others have made for you. Payments tnade
by cer•tain other� individuals and organizations also count toward your out-of-pocket
costs and help qualify you for catastrophic coverage. For example, payments made by a
State Pharmaceutical Assistance Program, an AIDS drug assistance program, the Indian
Health Service, and niost charities count toward your out-of-pocket costs. You should
keep a recot�d of these payments and send them to us so we can track your costs.
• Check the written report we send you. When you receive an Explanation of Benefits
(an EOB) in the mail, please look it over to be sure the information is complete and
correct. If you think something is missing from the report, or you have any questions,
please call us at Member Services (phone numbers at�e printed on the back cover of this
booklet). Be sure to keep these reports. They are an important record of your drug
expenses.
SECTION 4 During the Deductible Stage (if applicable), you pay the full
cost of your Part D drugs
Section 4.1
You stay in the Deductible Stage
cost sharing for your Part D drugs
until you have paid any applicable
The Deductible Stage is the first payment stage for your drug coverage. Your plan's deductible
amount (if applicable) is listed on the Prescription Drug Benefits Chart (Schedule of
Copayments/Coinsurance) included with this Evidence of Coverage. You must pay the full cost
of your drugs until you t•each the plan's deductible amount.
• Your "full cost" is usually lower than the normal full price of the drug, since our plan has
negotiated lower costs for most drugs.
The "deductible" is the amount you must pay for your Pat•t D prescription drugs before
the plan begins to pay its share.
Once you have paid your plan deductible arnount (if applicable), you leave the Deductible Stage
and move on to the next drug payment stage, which is the Initial Coverage Stage.
GRP_12 220 A 74 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chaptel• 6: What you pay for your Part D prescription drugs
SECTION 5 During the Initial Coverage Stage, the plan pays its share of
your drug costs and you pay your share
Section 5.1
What you pay for a drug depends on the drug and where you fill your
prescription
During the Initial Coverage Stage, the plan pays its shat�e of the cost of your covered prescription
drugs, and you pay your share (your copayment or coinsurance amount). Your share of the cost
will vary depending on the drug and where you fill your prescription.
The plan has a number of Cost-Sharing Tiers
Every drug on the plan's Drug List is in one of a number of cost-sharing tiers. In general, the
higher the cost-shat�ing tier number, the higher your cost for the drug: The tier• structure for your
plan is listed on the Prescription Drug Benefits Chart (Schedule of Copayments/Coinsurance)
included with this Evidence of Coverage.
To find out which cost-sharing tier your drug is in, look it up in the plan's Dr•ug List.
Your pharmacy choices
How much you pay for a drug depends on whether you get the drug fi�om:
• A retail pharmacy that is in our plan's network
• A pharmacy that is not in the plan's network
• The plan's mail-order pharmacy
For more information about these pharmacy choices and filling your prescriptions, see Chapter 5
in this booklet and the plan's Provider Directo�y.
Section 5.2 Refer to your Prescription Drug Benefits Chart for a table that shows
your costs for a one-montlt supply of a drug
During the Initial Cover�age Stage, your share of the cost of a covered drug will be either a
copayment or coinsurance.
"Copayment" means that you pay a fixed amount each time you fill a prescription.
"Coinsurance" means that you pay a percent of the total cost of the drug each time you
fill a prescription.
As shown in the table in the Prescription Drug Benefits chart (Schedule of Copayments/
Coinsurance) included with this Evidence of Coverage, the amount of the copayment or
coinsurance depends on which tier your drug is in. Please note:
• If your covered drug costs less than the copayment amount
pay that lower price fot� the drug. You pay eithey the fu
copayment amount, �vhicheve�� is lo��er�.
listed in the chart, you will
1 price of the drug or the
GRP 12 220 A 75 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 6: What you pay for your Part D prescription drugs
• We cover prescriptions filled at out-of-networ�k pharmacies in only limited situations.
Please see Chapter 5, Section 2.5 for information about when we will cover a prescription
ftlled at an out-of-network pharmacy.
Section 5.3 Refer to your Prescription Drug Benefits Chart for a table that shows
your costs for a long-term (up to a 90-day) supply of a drug
For some drugs, you can get a long-term supply (also called an "extended supply") when you fill
your prescription. A long-term supply is up to a 90-day supply. (For details on where and how to
get a long-terrn supply of a drug, see Chapter 5.)
As shown in the table in the Prescription Drug Benefits chart (Schedule of Copayments/
Coinsurance) included with this Evidence of Coverage, the amount of the copayment or
coinsurance depends on which tier� your drug is in.
• Please note: If your covered drug costs less than the copayment amount listed in the
chart, you will pay that lowet• price for the drug. You pay either the full price of the drug
or the copayment amount, tivhichever is lower•.
Section 5.4 You stay iu the Initial Coverage Stage until your total drug costs for
the year reach the initial coverage limit
You stay in the Initial Coverage Stage until the total amount fot� the prescription drugs you have
filled and r�efilled t�eaches the initial coverage limit for the Iuitial Coverage Stage. This
amount is listed on the Prescription Drug Benefits Chart (Schedule of Copayments/Coinsurance)
included with this Evidence of Coverage.
Your total drug cost is based on adding together what you have paid and what any Part D plan
has paid:
• What ou have paid for all the covet•ed drugs you have gotten since you started with
your ftrst drug purchase of the year. (See Section 6.2 for more information about how
Medicat•e calculates your out-of-pocket costs.) This includes:
• The amount of the plan deductible you paid when you were in tl�e Deductible
Stage (if applicable).
The total you paid as your share of the cost for your drugs during the Initial
Coverage Stage.
• What the plan has paid as its share of the cost for your drugs during the Initial
Coverage Stage. (If you were enrolled in a different Part D plan at any titne during 2013,
the amount that plan paid dut•ing the Initial Coverage Stage also counts toward your total
drug costs.)
Your former enzployer may offer additional coverage on sorne prescription dt�ugs that are not
norizially covered in a Medicare Pt•escription Drug Plan. Payments made for these drugs will not
count towards your initial coverage limit or total out-of-pocket costs. If included in your plan,
this will be listed in yout• Presct�iption Drug Benefits Chart (Schedule of Copayments/
GRP_12 220 A 76 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna Medicat�eSM Plan (HMO)
Chapter 6: What you pay for your Part D prescription drugs
Coinsurance) � under � the section "Enhanced Drug Benefit." � To find out which drugs our plan
covers, refer to yout• formulazy.
The Explanation of Benefits (EOB) that we send to you will help you keep track of how much
you and the plan have spent for your drugs during the year. Many people do not reach the initial
coverage limit in a year.
We will let you know if you reach the initial coverage limit amount. If you do reach this amount,
you will leave the Initial Coverage Stage and move on to the Coverage Gap Stage.
SECTION 6 During the Coverage Gap Stage, our plan may provide
some coverage, or you receive a discount on brand name
Section 6.1
drugs and pay no more than 79% of the costs for generic
drugs
You stay in the Coverage Gap Stage until your out-of-pocket costs
reach $4,750
The amount of your cost sharing during the Coverage Gap Stage is shown on the Prescription
Drug Benefits Chart (Schedule of Copayments/Coinsurance) included with this Evidence of
Coverage.
Brand drugs during the Coverage Gap Stage:
When you are in the Coverage Gap Stage, the Medicare Coverage Gap Discount Program
provides manufacturer discounts on brand name drugs. If your plan does not include
supplemental coverage for brand drugs you pay 47.5% of the negotiated price (excluding the
dispensing fee and vaccine administration fee, if any) for brand name drugs. Both the amount
you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs
as if you had paid them and moves you through the coverage gap. If your plan does include
supplemental coverage for brand drugs, the discount will be applied after your• plan benefits have
been determined.
Generic drugs duriug the Coverage Gap Stage:
You also receive some coverage for genet•ic drugs. If your� plan does not include suppleinental
coverage for generic drugs, you pay no more 79% of the cost for generic drugs and the plan pays
the rest. For generic drugs, the amount paid by the plan (21%) does not count toward your out-
of-pocket costs. Only the amount you pay counts and moves you through the coverage gap. If
your plan does include supplemental coverage for generic drugs, you will pay the applicable plan
copay fot• the cost sharing tier, and the amount you pay counts and moves you through the
coverage gap.
You continue paying the discounted price for brand name drugs and no more than 79% of the
costs of generic drugs until your yearly out-of-pocket payments reach a maximum amount that
Medicare has set. In 2013, that amount is $4,750.
GRP 12 220 A 77 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 6: What you pay for your Part D prescription drugs
Medicare has t�ules about what counts and what does not count as your out-of-pocket costs.
When you reach an out-of-pocket limit of $4,750, you leave the Coverage Gap Stage and move
on to the Catastrophic Coverage Stage.
Section 6.2 How Medicare calculates your out-of-pocket costs for prescription
drugs
Here are Medicare's rules that we must follow when we keep track of your out-of-pocket costs
for your drugs.
These paynaents aYe included in youY out-
of-nocket costs
When yozr add up your oict-of-pocket costs, you can include the peryrnents Zisted below (as long
as they are for Part D covef�ed dr•zcgs and yozc followed the rtcles for dr•Ztg coverage that are
explained in Chapte� S of this booklet):
• The amount you pay for drugs when you are in any of the following drug payment
stages:
.
:�
The Deductible Stage, if applicable to your plan.
The Initial Coverage Stage.
The Coverage Gap Stage.
Any payments you made during this calendar year as a member of a different Medicare
prescription drug plan before you joined our plan.
It matters who pays:
• If you make these payments yourself, they are included in your out-of-pocket costs.
• These payments are also included if they are made on your behalf by certain other
individuals or organizations. This includes payrnents for your drugs made by a friend
or relative, by most charities, by AIDS drug assistance programs, by a State
Phar•maceutical Assistance Progt•am that is qualified by Medicare, ar� by the Indian
Health Service. Payments made by Medicare's "Extra Help" Program are also included.
• Some of the payments made by the Medicare Coverage Gap Discount Program are
included. The amount the manufacturer pays for yout� brand name drugs is included. But
the amount the plan pays for your generic drugs is not included.
Movi�zg ott to tlie Catasti�ophic Cove�age Stage:
When yoza (or those perying on your behal� have spent a total of $4, 750 in out-of-�ocket costs
1-vithin the ccrlendai° yeaf; you i-vill �nove fro�n the Cove�age Gap Stczge to the Ccatastrophic
Covera�e Sta�e.
GRP_12 220 A 78 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chaptet� 6: What you pay for your Part D prescription drugs
These paynaents are not included in
vour out-of-pocket costs
When you add up your out-of-pocket costs, you are not allowed to include any of these types
of payments for prescription drugs:
• The amount you pay for your monthly premium (if applicable).
• Drugs you buy outside the United States and its territories.
• Drugs that at•e not covered by our plan.
• Drugs you get at an out-of-network pharmacy that do not meet the plan's requu•ements
for out-of-network coverage.
• Non-Part D drugs, including prescription drugs covered by Part A or Part B and other
drugs excluded fi�om coverage by Medicare.
• Payments made by the plan for your generic drugs while in the Coverage Gap.
• Payments for your drugs that are made by group health plans including employer health
p lans.
• Payments for your• drugs that are made by certain insur•ance plans and government-
funded health programs such as TRICARE and the Veteran's Administr�ation.
• Payments for your drugs made by a third-party with a legal obligation to pay for
prescription costs (for example, Workers' Compensation).
Reminder: If any othet� organization such as the ones listed above pays part or all of your out-
of-pocket costs for drugs, you are required to tell our plan. Call Member Services to let us know
(nhone numbers are nrinted on the back cover of this booklet).
How cun you keep t��rrck of your out-of-pocket total?
• We will help you. The Explcrnation of Benefits (EOB) report we send to you includes the
current amount of your out-of-pocket costs (Section 3 in this chapter tells about this
report). When you reach a total of $4,750 in out-of-pocket costs for the year, this report
will tell you that you have left the Coverage Gap Stage and have moved on to the
Catastrophic Coverage Stage.
• Make sure we have the information we need. Section 3.2 tells what you can do to help
make sure that our records of what you have spent are complete and up to date.
SECTION 7 During the Catastrophic Coverage Stage, the plan pays
most of the cost for your drugs
Section 7.1 Once you are in the Catastrophic Coverage Stage, you will stay in this
stage for the rest of the year
You qualify for the Catastrophic Coverage Stage when your out-of-pocket costs have reached the
$4,750 limit for the calendar year. Once you are in the Catastrophic Coverage Stage, you will
stay in this payment stage until the end of the calendar year.
The amount you pay dut•ing the Catastrophic Coverage Stage is shown on the Prescription Drug
Benefits Chart (Schedule of Copayments/Coinsurance.)
GRP 12 220 A 79 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 6: What you pay for your Part D prescription drugs
SECTION 8 What you pay for vaccinations covered by Part D depends
on how and where you get them
Section 8.1 Our plan has separate coverage for the Part D vaccine medication
itself and for the cost of giving you the vaccination shot
Our plan pt•ovides coverage of a number of Part D vaccines. We also cover vaccines that are
considered medical benefits. You can find out about coverage of these vaccines by going to the
Medical Benefits Chart included with this Evidence of Coverage.
There are two parts to our coverage of vaccinations:
• The fu•st part of coverage is the cost of the vaccine medication itseif. The vaccine is a
prescription medication.
• The second part of coverage is for the cost of giving you the vaccination shot. (This is
sometimes called the "administration" of the vaccine.)
What do you pay for a Part D vaccination?
What you pay for a Part D vaccination depends on three things:
1. The type of vaccine (what you are being vaccinated for).
• Some vaccines are considered medical benefits. You can find out about your
coverage of these vaccines by going to the Medical Benefits Chart included with
this Evidence of Coverage.
• Other vaccines are considered Pat-t D drugs. You can find these vaccines listed in
the plan's List of Covered Drugs (Formulary).
2. Where you get the vaccine medication.
3. Who gives you the vaccination shot.
VJhat you pay at the time you get the Part D vaccination can vaiy depending on the
cu•cumstances. For example:
• Sometimes when you get your vaccination shot, you will have to pay the entu�e cost for
both the vaccine medication and for getting the vaccination shot. You can ask our plan to
pay you back for our share of the cost.
• Other times, when you get the vaccine medication or the vaccination shot, you will pay
only your share of the cost.
To show how this wot•ks, here are three common ways you might get a Part D vaccination shot.
Remember you are responsible for all of the costs associated with vaccines (including their
adtninistration) during the Deductible, (if applicable) and Coverage Gap Stage of your benefit
(unless the vaccine is included in a drug tier for which plan supplemental coverage is offered).
GRP_12 220 A 80 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 6: What you pay for your• Part D prescription drugs
� .,�. _
Sitzration 1: You buy the Part D vaccine at the pharmacy and you get your vaccination shot at
the network pharmacy. (Whether you have this choice depends on where you live.
Some states do not allow pharmacies to administer a vaccination.)
• You will have to pay the pharmacy the amount of your coinsui•ance or
copayment for the vaccine itself.
• Our plan will pay for the cost of giving you the vaccination shot.
Situation 2: You get the Part D vaccination at your doctor's office.
• When you get the vaccination, you will pay for the entire cost of the
vaccine and its administration.
• You can then ask our plan to pay our share of the cost by using the
procedures that are described in Chapter 7 of this booklet (Asking zrs to
pay our share of a bill you have received foN covet�ed medical services or
LZYLigS�.
• You will be reimbursed the amount you paid less your normal coinsurance
or copayment for the vaccine (including administration) less any
difference between the amount the doctor charges and what we normally
pay. (If you get Extra Help, we will reimburse you for this difference.)
Sitzcation 3: You buy the Part D vaccine at your pharmacy,
office where they give you the vaccination shot.
• You will have to pay the pharmacy the
copayment for the vaccine itself.
and then take it to your doctor's
amount of your coinsurance or
• When your doctor gives you the vaccination shot, you will pay the entire
cost for this setvice. You can then ask our plan to pay our share of the cost
by using the procedures described in Chapter 7 of this booklet.
Section 8.2
You will be reimbursed the amount charged by the doctor for
administering the vaccine less any difference between the amount the
doctor charges and what we normally pay. (If you get Extra Help, we will
reimburse you for this difference.)
You may want to call us at Member Services before you get a
vaccination
The rules for coverage of vaccinations are complicated. We are here to help. We recominend that
you call us first at Member Seivices whenever you are planning to get a vaccination. (Phone
numbers for Membe�� Services are printed on the back cover of this booklet.)
• We can tell you about how your vaccination is covered by our plan and explain your
share of the cost.
GRP 12 220 A 81 HMO EOGwith RY (Y2013)
2013 Evidence of Coverage for Aetna Medicat•eSM Plan (HMO)
Chapter 6: What you pay for your Part D prescription drugs
• We can tell you how to keep your own cost down by using providers and pharmacies in
our network.
• If you are not able to use a network pr•ovider and pharmacy, we can tell you what
you need to do to get payment from us for our share of the cost.
SECTION 9
Section 9.1
Do you have to pay the Part D"late enrollment penalty"?
What is the Part D"late enrollment penalty"?
Note: If you receive "Extra Help" from Medicare to pay for your prescription drugs, the late
enrollment penalty rules do not apply to you. You will not pay a late enrollment penalty, even if
you go without "creditable" prescription drug covet�age.
You may pay a financial penalty if you did not enroll in a plan offering Medicare Part D drug
coverage when you fitst became eligible for this drug coverage or you experienced a continuous
period of 63 days or more when you didn't have creditable prescription drug coverage.
("Creditable prescription drug coverage" is coverage that meets Medicare's minimum standards
since it is eYpected to pay, on average, at least as inuch as Medicare's standard prescription drug
coverage.) The amount of the penalty depends on how long you waited to enroll in a creditable
prescription drug coverage plan any time after the end of your initial enrollment period or how
many full calendar months you went without creditable prescription drug coverage. You will
have to pay this penalty for� as long as you have Part D covet�age.
The penalty is added to your inonthly premiuin (if applicable). Your late enrollment penalty is
considered part of yout� plan premium. If you do not pay your late enrollment penalty, you could
be disenrolled for failure to pay your plan premiutn.
Section 9.2 How much is the Part D late enrollment penalty?
Medicare determines the amount of the penalty. Here is how it works:
• First count the number of full months that you delayed em�olling in a Medicare drug plan,
after you were eligible to em•oll. Or count the number of full months in which you did not
have creditable prescription drug coverage, if the break in coverage was 63 days or mot•e.
The penalty is 1% for eveiy month that you didn't have creditable coverage. For
exarnple, if you go 14 months without coverage, the penalty will be 14°/o.
• Then Medicare determines the amount of the average monthly premium for Medicare
drug plans in the nation fi•om the previous year. For 2013, this aeerage premium amount
is $31.17
• To get your monthly penalty, you multiply the penalty percentage and the avet•age
monthly premium and then round it to the neat•est 10 cents. In the example here it would
be 14% times $31.17. This equals $4.36, which rounds to $4.40. This amount would be
added to the monthly premium for someone �vith a late enrollment penalty.
GRP_12 220 A 82 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna Medicat•eSM Plan (HMO)
Chapter 6: What you pay for your Part D prescription drugs
., � _ _. _. . �..._ _ � . __, _ . _ . _�
There are three important things to note about this monthly late enrollment penalty:
• First, the penalty may change each year, because the average monthly premium can
change each year. If the national average premium (as determined by Medicare)
increases, your penalty will increase.
• Second, you will continue to pay a penalty every month for as long as you are enrolled
in a plan that has Medicare Part D drug benefits.
• Third, if you are under 65 and currently receiving Medicare benefits, the late enrollment
penalty will reset when you turn 65. After age 65, your late enrollment penalty will be
based only on the months that you don't have coverage after yout• initial enrollment
period for aging into Medicare.
Section 9.3
In some situations, you can enroll late and not have to pay the penalty
Even if you have delayed enrolling in a plan offering Medicare Part D coverage when you were
first eligible, sometimes you do not have to pay the late enrollment penalty.
You will not have to pay a penalty for late enrollment if you are in any of these situations:
• If you already have prescription drug coverage that is expected to pay, on average, at
least as much as Medicare's standard prescription drug coverage. Medicare calls this
"creditable drug coverage." Please note:
• Creditable coverage could include drug coverage from a former employer or
union, TRICARE, or the Department of Veterans Affairs. Your insurer or your
human resources department will tell you each year if your drug coverage is
creditable coverage. This information may be sent to you in a letter or included in
a newsletter from the plan. Keep this information, because you may need it if you
join a Medicare drug plan later.
• Please note: If you receive a"certificate of creditable coverage" when
your health coverage ends, it may not mean your prescription drug
��
coverage was creditable. The notice must state that you had "creditable"
prescription drug coverage that expected to pay as much as Medicare's
standard prescription drug plan pays.
• The following are not creditable presct•iption drug coverage: pr•escription drug
discount cat•ds, fi•ee clinics, and drug discount websites.
• For additional information about creditable coverage, please loolc in your
Medicare & You 2013 Handbook or call Medicare at 1-800-MEDICARE (1-800-
633-4227). TTY users call 1-877-486-2048. You can call these numbers for free,
24 houl•s a day, 7 days a week.
If you were without creditable coverage, but you were without it for less than 63 days in a
row.
If you are receiving "Extra Help" fi�om Medicare.
GRP 12 220 A 83 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 6: VJhat you pay for yout• Part D prescription drugs
Section 9.4 What can you do if you disagree about your late enrollment penaliy?
If you disagree about your late enrollment penalty, you ot• your representative can ask for a
t�eview of the decision about your late enrolhnent penalty. Generally, you must request this
review within 60 days from the date on the letter you receive stating you have to pay a late
enrollment penalty. Call Member Services to find out more about how to do this (phone numbers
are printed on the back cover of this booklet).
Important: Do not stop paying your late enrolhnent penalty while you're waiting for a review of
the decision about your late enrollment penalty. If you do, you could be disenrolled for failure to
pay your plan premiums.
SECTION 10
Section 10.1
Do you have to pay an extra Part D amount because of your
income?
Who pays an extra Part D amount because of income?
Most people pay a standard monthly Part D premium. However, some people pay an extra
amount because of theit• yearly income. If your� income is $55,000 or above for an individual (or
married individuals filing separ•ately) or $170,000 or above for mat•ried couples, you must pay an
extra amount directly to the government for your Medicare Part D coverage.
If you have to pay an extra amount, Social Security, not your Medicare plan, will send you a
letter telling you what that extra amount will be and how to pay it. The extra amount will be
withheld fi•om yout• Social Security, Railroad Retirement Board, or Office of Personnel
Management benefit check, no matter how you usually pay your plan premium, unless your
monthly benefit isn't enough to cover the extra arnount owed. If your benefit check isn't enough
to cover the extra amount, you will get a bill from Medicare. The extra amount must be paid
separately and cannot be paid with your monthly plan premium.
Section 10.2 How much is the extra Part D amount?
If your modified adjusted gross income (MAGI) as reported on youi• IRS tax t�eturn is above a
certain amount, you will pay an extra amount in addition to your monthly plan premium.
GRP_12 220 A 84 HMO EOC—with R�c (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chaptei• 6: What you pay for your Part D prescr•iption drugs
_
The chart below shows the extra amount based on yout� income.
� If you fled an If you were married if you filed a joint This is the monthly �
individual tax � but filed a separate tax return and your : cost of your extra
return and your tax return and your income in 2011 was: Part D amount (to
� income in 2011 was: income in 2011 was: ; be paid in addition
� : to your plan
�— - �„_� �..�_w�.���, � w�r7��_.w�i�_..µ�, , ,�-w r._,r�;.c> _�.� .T ��._v_����wPremium �.��v.w _�.
_ )
° Equal to or less than Equal to or less than Equal to or less than � ��
$85,000 $85,000 $170,000 �� �
�_�� ��-rr--��� �_�-a._����:� �� _�: ����_�._N �� �., ,,� � .�_�w� ���.� ��_:— ��.�tY_.__ . _���
� Greater than $85,000 Gr�eater than ��
and less than or equal $170,000 and less $11.60 �
to $107,000 than or equal to
$214,000
Greatet� than Gr•eater than
$107,000 and less $214,000 and less $29.90
than or equal to than or equal to
�, $160,000 $320,000
� � ��-�,�.��� �� ���� �-���_� �� � � � ���r_� �m �� ��-�_.,�_--�_��.�.�. � w��
Greater than Greater than $85,000 Greater than
$160,000 and less and less than or equal $320,000 and less �48.30
than ot• equal to to $129,000 than or equal to
$214,000 $428,000
Greater than Greater than Greater than $66.60
$214,000 $129,000 $428,000
��.� ��..,p,���,_ ��_;_ ,_�,�_,�_�_.,_� _.,,.��_... r�. . ,�_���.��w�a����r_„���____,:1� w�-as
Section 10.3 What can you do if you disagree about paying an extra Part D
amount?
If you disagree about paying an extra amount because of your income, you can ask Social
Security to review the decision. To find out more about how to do this, contact Social Security at
1-800-772-1213 (TTY 1-500-325-0778).
Section 10.4 What happens if you do not pay the extra Part D amount?
The extra amount is paid directly to the government (not your Medicare plan) for your Medicare
Part D coverage. If you are required to pay the extra ainount and you do not pay it, you will be
disenrolled from the plan and lose prescription drug coverage.
GRP 12 220 A 85 HMO EOC—with R�c (Y2013)
2013 Evidence of Coverage for Aetna MedicaresM Plan (F�10)
Chapter 7: Asking us to pay our share of a bill you have received for covered medical seivices or
drugs
Chapter 7. Asking us to pav our share of a bill vou have received for covered
medical services or drugs
SECTION 1 Situations in which you should ask us to pay our share of the cost of your
covered services or drugs
Section 1.1 If you pay our plan's share of the cost of your covered services or
drugs, or if you receive a bill, you can ask us for payment
SECTION 2 How to ask us to pay you back or to pay a bill you have received
Section 2.1 How and where to send us your request for payment
SECTION 3 We will consider your request for payment and say yes or no
Section 3.1 We check to see whether we should cover the service or drug and
how much we owe
Section 3.2 If we tell you that we will not pay for all or part of the medical care
or drug, you can make an appeal
SECTION 4 Other situations in which you should save your receipts and send copies to us
Section 4.1 In some cases, you should send copies of your r•eceipts to us to
help us track your out-of-pocket drug costs
GRP_12 220 A 86 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 7: Asking us to pay our share of a bill you have received for covered medical setvices or
diugs
SECTION 1
Situations in which you should ask us to pay our share of
the cost of your covered services or drugs
Section l.l If you pay our plan's share of the cost of your covered services or
drugs, or if you receive a bill, you can ask us for payment
Sometimes when you get medical care or a prescription drug, you may need to pay the full cost
right away. Other times, you may find that you have paid more than you expected under the
coverage rules ofthe plan. In either case, you can ask our plan to pay you back (paying you back
is often called "reimbuz�sing" you). It is your right to be paid back by our plan whenever you've
paid more than your share of the cost for medical services or drugs that are covered by our plan.
There may also be times when you get a bi11 from a provider for the full cost of inedical care you
have received. In many cases, you should send this bill to us instead of paying it. We will look at
the bill and decide whether the services should be covered. If we decide they should be covered,
we will pay the provider directly.
Here are examples of situations in which you may need to ask our plan to pay you back or to pay
a bill you have received:
1. When you've received medical care from a provider who is not in our plan's
network
You can receive emergency seivices fi�om any provider, whether or not the provider is a
part of our network. When you receive emergency or urgently needed care from a
provider who is not part of our network, you are only responsible for paying your share
of the cost, not for the entu�e cost. You should ask the provider to bill the plan for our
share of the cost.
• If you pay the entu•e amount yourself at the time you receive the care, you need to
ask us to pay you back fot• our share of the cost. Send us the bill, along with
documentation of any payments you have made.
• At times you may get a bill fi�om the provider asking for payment that you think
you do not owe. Send us this bill, along with documentation of any paytnents you
have already made.
• If the providei• is owed anything, we will pay the provider directly.
• If you have already paid more than your share of the cost of the service,
we will determine how much you owed and pay you back for our shar•e of
the cost.
2. When a network provider sends you a bill you think you should not pay
Network providers should always bill the plan directly, and ask you only for your share
of the cost. But sometimes they make mistakes, and ask you to pay more than your share.
• You only have to pay your cost-sharing amount when you get services covered by
out� plan. We do not ailow providers to add additional separ�ate charges, called
"balance billing." This protection (that you never pay more than yout• cost-sharing
GRP 12 220 A 87 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna Medicat�eSM Plan (HMO)
Chapter• 7: Asking us to pay our shar�e of a bill you have received for covered medical services or
drugs
� �, . , � �, . . ..
ainount) applies even if we pay the provider less than the provide�� charges for a
service and even if there is a dispute and we don't pay certain provider chaiges.
For more information about "balance billing," go to Chapter 4, Section 1.3.
• Whenever you get a bill from a network provider that you think is more than you
should pay, send us the bilL We will contact the provider di�•ectly and resolve the
billing problem.
• If you have already paid a bill to a network provider, but you feel that you paid
too much, send us the bill along with documentation of any payment you have
made and ask us to pay you back the difference between the amount you paid and
the amount you owed under the plan.
3. If you are retroactively enrolled in our plan.
Sometimes a person's eru�ollment in the plan is retroactive. (Rett�oactive means that the
first day of their enrollment has already passed. The enrollment date may even have
occurred last yeat•.)
If you wet•e rett•oactively enrolled in our plan and you paid out-of-pocket for any of your
covered services or drugs after your enroliment date, you can ask us to pay you back for
our• share of the costs. You will need to submit paperwork for us to handle the
reimbursement.
• Please call Member Services for additional information about how to ask us to
pay you back and deadlines for making your request. (Phone numbers for
Member Services are printed on the back cover� of this booklet.)
4. When you use an out-of-network pharmacy to get a prescription flled
If you go to an out-of-network pharmacy and try to use your membetship card to fill a
prescription, the pharmacy may not be able to submit the ciaim directly to us. When that
happens, you will ha�e to pay the full cost of your pt�escription. (We cover prescriptions
filled at out-of-networ•k pharmacies only in a few special situations. Please go to Chapter
5, Sec. 3.5 to learn more.)
• Save your receipt and send a copy to us when you ask us to pay you back for our
share of the cost.
5. When you pay the full cost for a prescription because you don't have your plan
membership card with you
If you do not have yout• plan membeiship card with you, you can ask the pharmacy to call
the plan or to look up your plan ent�oliment infor•mation. However, if the pharmacy
cannot get the enrollment information they need right away, you may need to pay the full
cost of the presct•iption yourself.
• Save your receipt and send a copy to us when you ask us to pay you back fot� our
share of the cost.
GRP_12_220 A 88 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 7: Asking us to pay our share of a bill you have received for covered medical seivices or
drugs
6. When you pay the full cost for a prescription in other situations
You may pay the full cost of the prescription because you find that the drug is not
covered for some reason.
• For example, the drug may not be on the plan's List of Covered Drugs
(Fori�zulary); or it could have a requu•ement or restriction that you didn't know
about or don't think should apply to you. If you decide to get the drug
immediately, you may need to pay the full cost for it.
• Save your receipt and send a copy to us when you ask us to pay you back. In
some situations, we may need to get more information fi�om your doctor in order
to pay you back for our share of the cost.
All of the examples above are types of coverage
request for payment, you can appeal our decision.
have a pf•oblem or complaznt (coverage decisions,
how to make an appeal.
SECTION 2
Section 2.1
decisions. This means that if we deny your
Chapter 9 of this booklet (Whcrt to do �you
appeals, complaints)) has information about
How to ask us to pay you back or to pay a bill you have
received
How and where to send us your request for payment
Send us your request for payment, along with your bill and documentation of any payment you
have made. It's a good idea to make a copy of your bill and receipts for your records.
For prescription drug claims, to make sure you are giving us all the information we need to
make a decision, you can fill out our claim form to make your request for� payment.
• You don't have to use the form, but it will help us process the information faster.
• Either download a copy of the form $�om our website (www.aetnaetireeplans.com) or call
Member Services and ask for the form. The phone numbers for Member Seivices are on
the back cover of this booklet.
• Mail to us at:
Aetna Pharmacy Management
Attn: Medicat�e Processing
P.O. Box 14023
Lexington, KY 40512-4023
For medical claims, mail your request for payment together with any bills or t�eceipts to us at the
address below.
Aetna
P.O. Box 981106
EI Paso, TX 79998-1106
GRP 12 220 A 89 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage fot� Aetna Medicar�eSM Plan (HMO)
Chapter 7: Asking us to pay our share of a bill you have t•eceived for covered medical services or
drugs
_ . �., �� , � w.. _. ....,
Contact Mernber Services if you have any questions (phone numbers are printed on the back
cover of this booklet). If you don't know what you should ha�e paid, or you receive bills and you
don't know what to do about those bills, we can help. You can also call if you want to give us
mor•e information about a request for payment you have already sent to us.
SECTION 3
Section 3�.1
We will consider your request for payment and say yes or
no
We check to see whether we should cover the service or drug and how
much we owe
When we receive your request for• payment, we will let you know if we need any additional
information from you. Otherwise, we will consider your request and make a coverage decision.
• If we decide that the medical care or drug is covered and you followed all the rules for
getting the care or drug, we will pay for our shat�e of the cost. If you have already paid for
the service or drug, we will mail your reimbursement of our shar•e of the cost to you. If
you have not paid for the service or drug yet, we will mail the payment directly to the
provider. (Chapter 3 explains the rules you need to follow for getting your medical
services covered. Chapter 5 explains the lules you need to follow for getting your Part D
prescription drugs covered.)
• If we decide that the medical care or drug is not covered, or you did not follow all the
rules, we will not pay for our share of the cost. Instead, we will send you a letter that
explains the reasons why we are not sending the payment you have requested and your
rights to appeal that decision.
Section 3.2 If we tell you that we will not pay for all or part of the medical care or
drug, you can make an appeal
If you think we have made a mistake in turning down your request for payment or you don't
agree with the amount we are paying, you can make an appeal. If you make an appeal, it tneans
you ar•e asking us to change the decision we made when we tut•ned down your request for
payment.
For the details on how to make this appeal, go to Chapter 9 of this booklet (What to do i.f yoz�
hm�e a�J°oble�n or• corfzplaint (coverage decisions, uppeals, complaints)). The appeals process is
a formal process with detailed procedures and important deadlines. If making an appeal is new to
you, you will find it helpful to start by reading Section 4 of Chapter� 9. Section 4 is an
introductory section that explains the process for coverage decisions and appeals and gives
definitions of terms such as "appeal." Then after you have r�ead Section 4, you can go to the
section in Chapter 9 that tells what to do fot• your situation.
• If you want to malce an appeal about getting paid back for a medical service, go to
Section 5.3 in Chapter 9.
GRP_12 220 A 90 HMO EOC—with R�c (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 7: Asking us to pay our share of a bill you have received for covered medical services or
drugs
� , v_ _ _ �_ _ .. �. _ � �
• If you want to make an appeal about getting paid back for a drug, go to Section 6.5 of
Chapter 9.
SECTION 4
Other situations in which you should save your receipts and
send copies to us
Section 4.1 In some cases, you should send copies of your receipts to us to help us
track your out-of-pocket drug costs
There are some situations when you should let us know about payments you have made for your
drugs. In these cases, you are not asking us for payment. Instead, you at•e telling us about your
payments so that we can calculate your out-of-pocket costs correctly. This may help you to
qualify for the Catastrophic Coverage Stage more quickly.
Here are two situations when you should send us copies of r•eceipts to let us know about
payments you have made for your drugs:
1. When you buy the drug for a price that is lower than our price
Sometimes when you are in the Coverage Gap Stage you can buy your drug at a network
pharmacy for a price that is lower than our price.
• For example, a pharmacy might offer a special price on the drug. Or you may
have a discount card that is outside our benefit that offers a lower price.
• Unless special conditions apply, you must use a network pharmacy in these
situations and your drug must be on our Drug List.
• Save your receipt and send a copy to us so that we can have your out-of-pocket
expenses count toward qualifying you for the Catastrophic Cover�age Stage.
• Please note: If you are in the Coverage Gap Stage, we may not pay for any share
of these drug costs. But sending a copy of the receipt allows us to calculate your
out-of-pocket costs correctly and may help you qualify for the Catastrophic
Covet�age Stage more quickly.
2. When you get a drug through a patient assistance program offered by a drug
manufacturer
Some members are enrolled in a patient assistance program offered by a drug
manufacturer that is outside the plan benefits. If you get any drugs tht�ough a program
offered by a drug manufacturer, you may pay a copayment to the patient assistance
program.
• Save your receipt and send a copy to us so that we can have yom� out-of-pocket
expenses count toward qualifying you for the Catastrophic Covet�age Stage.
• Please note: Because you are getting your drug through the patient assistance
program and not tlu•ough the plan's benefits, we will not pay for any share of
these drug costs. But sending a copy of the receipt allows us to calculate your out-
GRP 12 220 A 91 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 7: Asking us to pay our share of a bill you have received for covered medical services or
drugs
� _ � . ...
of-pocket costs correctly and may help you qualify for the Catastrophic Coverage
Stage more quickly.
Since you ar•e not asking fot• payment in the two cases described above, these situations are not
considered coverage decisions. Therefore, you cannot tnake an appeal if you disagree with our
decision.
GRP_i2 220 A 92 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 8: Your rights and responsibilities
Chapter 8. Your ri�hts and responsibilities
SECTION 1 Our plan must honor your rights as a member of the plan
Section 1.1 We must provide infotmation in a way that works for you (in
languages other than English, in Braille, in large print, or other•
alter•nate formats, etc.)
Section 1.2 We must treat you with fairness and respect at all times
Section 1.3 We must ensure that you get timely access to your covered
Section 1.4
Section 1.5
Section 1.6
Section 1.7
Section 1.8
Section 1.9
seivices and drugs
We must protect the privacy of your personal health information
We must give you information about the plan, its network of
providers, and your covered services
We must support your right to make decisions about your care
You have the right to make complaints and to ask us to reconsider
decisions we have made
What can you do if you believe you are being tt•eated unfairly or
your rights are not being respected?
How to get more information about your rights
SECTION 2 You have some responsibilities as a member of the plan
Section 2.1 What are your responsibilities?
GRP 12 220 A 93 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 8: Your rights and responsibilities
SECTION 1 Our plan must honor your rights as a member of the plan
Section 1.1 We must provide information in a way that works for• you (in
lauguages other than English, in Braille, in large print, or other
alternate formats, etc.)
Debemos proveer informacion en un formato que sea adecuado para
usted (en idiomas distintos del utilizado en este folleto, en braille, en
letra grande u otros formatos alternativos, etc.)
To get information from us in a way that wot�ks for you, please call Membet• Services (phone
numbers are printed on the back cover of this booklet).
Our plan has people and fi�ee language interpreter services available to answer questions from
non-English speaking members. We can also give you information in Br•aille, in large print, or
other alternate formats if you need it. If you are eligible for Medicare because of a disability, we
are required to give you information about the plan's benefits that is accessible and appropriate
for you.
If you ha�e any trouble getting infoz�mation fi�om our plan because of problems related to
language or a disability, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours
a day, 7 days a week, and tell them that you want to file a complaint. TTY users call 1-877-486-
2048.
Section 1.2 We must treat you with fairness and respect at all times
Our plan must obey laws that pr•otect you fi•om discrimination or unfair treatment. We do not
discrimivate based on a person's race, ethnicity, national origin, religion, gender, age, tnental or
physical disability, health status, claims experience, medical history, genetic information,
evidence of insurability, or geographic location within the service ai•ea.
If you want more information or have concerns about discriiziination or unfait� tr•eattnent, please
call the Department of Health and Human Services' Offce for Civil Rights 1-800-368-1019
(TTY 1-800-537-7697) or your local Office for Civil Rights.
If you have a disability and need help with access to care, please call us at Membet� Setvices
(phone numbers are printed on the back cover of this booklet). If you have a complaint, such as a
probletn with wheelchair access, Member Services can help.
Section 1.3 We must ensure that you get timely access to your covered services
aud drugs
As a member of our plan, you have the right to choose a primary care provider (PCP) in the
plan's network to provide and arrange for your covered services (Chaptet• 3 explains more about
this). Call Member Services to learn which doctot•s are accepting new patients (phone nuuibers
GRP_12_220 A 94 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 8: Your rights and responsibilities
are printed on the back cover ofthis booklet). You also have the right to go to a women's health
specialist (such as a gynecologist) without a referral.
As a plan member, you have the right to get appointments and covered services from your
providers within a reasonable amount of time. This includes the right to get timely services from
specialists when you need that care.
If you think that you are not getting your medical care or Part D drugs within a reasonable
amount of titne, Chapter 9, Section 10 of this booklet tells what you can do. (If we have denied
coverage for your medical care or drugs and you don't agree with our decision, Chapter 9,
Section 4 tells what you can do.)
Section 1.4 We must protect the privacy of your personal health information
Federal and state laws protect the pt•ivacy of your medical records and personal health
information. We protect your personal health information as required by these laws.
• Your "personal health information" includes the personal information you gave us when
you enrolled in this plan as well as your medical records and other medical and health
infor�mation.
• The laws that protect your privacy give you rights related to getting information and
controlling how your health information is used. We give you a written notice, called a
"Notice of Privacy Practice," that tells about these rights and explains how we protect the
privacy of your health information.
How do we protect the privacy of your health information?
• We make sure that unauthorized people don't see or change your records.
• In most situations, if we give yout• health information to anyone who isn't providing your
care or paying for your care, we are required to get written pern7ission fi�om you first.
Written permission can be given by you or by someone you have given legal power to
make decisions for you.
• There are certain exceptions that do not require us to get your wt•itten permission first.
These exceptions are allowed or required by law.
• For exatnple, we are required to release health information to government
agencies that are checking on quality of care.
• Because you are a member of our plan through Medicare, we are requu•ed to give
Medicat•e your health inforrnation including information about your Part D
prescr�iption drugs. If Medicare releases your information for research or other
uses, this will be done according to federal statutes and regulations.
You can see the information in your records and know how it has been shat•ed with others
You have the right to look at your medical records held at the plan, and to get a copy of your
records. We are allowed to charge you a fee for making copies. You also have the right to ask us
GRP 12 220 A 95 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 8: Your rights and responsibilities
�. �. � . .. . � .. .. .
to make additions or corrections to your medical records. If you ask us to do this, we will work
with your healthcare provider to decide whether the changes should be rnade.
You have the right to know how your health information has been shared with others for any
purposes that are not routine.
If you have questions or concerns about the privacy of your personal health information, please
call Member Services (phone numbers are printed on the back cover of this booklet).
Section 1.5 We must give you information about the plan, its network of
providers, and your covered services
As a member of our plan, you have the right to get several kinds of information from us. (As
explained above in Section 1.1, you have the right to get information from us in a way that works
for you. This includes getting the information in languages other than English and in large print
or other alternate formats.)
If you want any of the following kinds of information, please call Member Services (phone
numbers are pt•inted on the back cover of this booklet):
• Information about our plan. This includes, for example, information about the plan's
financial condition. It also includes information about the number of appeals made by
members and the plan's performance ratings, including how it has been rated by plan
rnembers and how it compares to other Medicare health plans.
• Information about our network providers including our network pharmacies.
• For example, you have the right to get information fl�om us about the
qualifications of the providers and pharmacies in our netwot�k and how we pay the
providers in our network.
For a list of the providers and pharmacies in the plan's network, see the Pr•ovider
Directofy.
• For more detailed ulformation about our pt•oviders or pharmacies, you can call
Member Services (phone numbers are printed on the back cover of this booklet)
ot visit out� website at http://www.aetnaretit•eeplans.com.
• Information about your coverage and rules you must follow iu usiug your coverage.
• In Chapteis 3 and 4 of this booklet, we explain what inedical services are covered
for you, any t�estrictions to your coverage, and what rules you must follow to get
your covered medical set•vices.
• To get the details on your Part D prescription drug coverage, see Chapters 5 and 6
of this booklet plus the plan's Last of Covef�ed Drugs (Formulary). These chapters,
together with the List of Covered D�•acgs (Formzrlary), tell you what drugs are
covered and explain the rules you must follow and the restrictions to your
coverage for certain drugs.
GRP_12 220 A 96 HMO EOGwith l� (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 8: Your rights and responsibilities
• If you ha�e questions about the rules or restrictions, please cail Member Services
(phone numbers are printed on the back cover of this booklet).
• Information about why something is not covered and what you can do about it.
• If a medical service or Part D drug is not covered for you, or if your coverage is
restricted in some way, you can ask us for a written explanation. You have the
right to this explanation even if you received the medical service or drug from an
out-of-network provider or pharmacy.
• If you are not happy or if you disagree with a decision we make about what
medical care ot• Part D drug is covered for you, you have the right to ask us to
change the decision. You can ask us to change the decision by making an appeal.
For details on what to do if something is not covered for you in the way you think
it should be covered, see Chapter 9 of this booklet. It gives you the details about
how to make an appeal if you want us to change our decision. (Chapter 9 also tells
about how to make a complaint about quality of care, waiting times, and other
concerns.)
• If you want to ask our plan to pay our share of a bill you have received for
medical care or a Part D prescription drug, see Chapter 7 of this booklet.
Section 1.6 We must support your right to malce decisions about your care
You have the right to know your treatment options and participate in decisions about your
IiT�1�P��
You have the right to get full information from your doctors and other health care provideis
when you go for medical care. Your providers must explain your medical condition and your
treatment choices in a wr.cy that you can zcnderstcrnd.
You also have the right to participate fully in decisions about your health care. To help you make
decisions with your doctors about what treatment is best for you, your rights include the
fo llowing:
• To know about all of your choices. This means that you have the right to be told about
all of the treatment options that are recommended for your condition, no matter what they
cost or whether they are covered by our plan. It also includes being told about programs
out� plan offers to help members manage their medications and use drugs safely.
• To l�now about the risks. You have the right to be told about any risks involved in your
care. You must be told in advance if any proposed medical care or treatment is part of a
research experiment. You always have the choice to t�efuse any experimental treatments.
• The right to say "no." You have the right to refuse any recommended treatment. This
includes the right to leave a hospital ot• other medical facility, even if your doctor advises
you not to leave. You also have the right to stop taking your medication. Of course, if you
GRP 12 220 A 97 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage fot� Aetna MedicareSM Plan (HMO)
Chapter 8: Your rights and responsibilities
refuse treatment or stop taking medication, you accept full responsibility for• what
happens to your body as a result.
• To receive an explanation if you are denied coverage for care. You have the right to
receive an explanation fi•om us if a provider has denied care that you believe you should
receive. To receive this explanation, you will need to ask us for a coverage decision.
Chapter 9 of this booklet tells how to ask the plan for a coverage decision.
You have the right to give instructions about what is to be done if you are not able to make
medical decisions for yourself
Sometimes people become unable to make health care decisions for themselves due to accidents
or serious illness. You have the right to say what you want to happen if you are in this situation.
This means that, ifyozc want to, you can:
• Fill out a written form to give someone the legal authority to make medical decisions
for you if you ever become unable to make decisions for yourself.
• Give your doctors written instructions about how you want them to handle your
medical care if you become unable to make decisions for yourself.
The legal documents that you can use to give your dit•ections in advance in these situations are
called "advance directives." Thet•e are different types of advance directives and different names
for them. Documents called "living will" and "power of attorney for health care" are examples
of advance d'u�ectives.
If you want to use an "advance directive" to give your instructions, here is what to do:
• Get the form. If you want to have an advance directive, you can get a form from your
lawyet�, fi•om a social worker, or fi�om some office supply stor�es. You can sometimes get
advance directive forms fi•om organizations that give people information about Medicare.
You can also contact Member Services to ask for the forms (phone numbers are printed
on the back cover of this booklet).
• Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a
legal document. You should consider having a lawyer help you pt�epare it.
• Give copies to appropriate people. You should give a copy of the form to your doctor
and to the person you name on the form as the one to make decisions for you if you can't.
You may want to give copies to close friends or family members as we11. Be sut•e to keep
a copy at home.
If you know ahead of time that you are going to be hospitalized, and you have signed an advance
dit•ective, take a copy with you to the hospital.
• If you are admitted to the hospital, they will ask you whether you have signed an advance
di��ective fot•m and whether you have it with you.
• If you ha�e not signed an advance directive form, the hospital has fornls available and
will ask if you want to sign one.
GRP_12 220 A 98 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 8: Your rights and responsibilities
Remember, it is your choice whether you want to fll out an advance directive (including
whether you want to sign one if you are in the hospital). According to law, no one can deny you
care or discriminate against you based on whether or not you have signed an advance directive.
What if your instructions are not followed?
If you have signed an advance directive, and you believe that a doctor or hospital did not follow
the instructions in it, you may file a complaint with your state's Department of Health.
Section 1.7
You have the right to make complaints and to ask us to reconsider
decisions we have made
If you have any problems or concerns about your covered services or care, Chapter 9 of this
booklet tells what you can do. It gives the details about how to deal with all types of problems
and complaints.
As explained in Chapter 9, what you need to do to follow up on a problem or concern depends on
the situation. You might need to ask our plan to make a coverage decision for you, make an
appeal to us to change a coverage decision, or make a complaint. Whatever you do — ask for a
coverage decision, make an appeal, or make a complaint — we are required to treat you fairly.
You have the t•ight to get a summary of information about the appeals and complaints that other
members have filed against our plan in the past. To get this information, please call Member
Services (phone numbers are printed on the back cover of this booklet).
Section 1.8 What can you do if you believe you are being treated unfairly or your
rights are not being respected?
If it is about discrimination, call the Office for Civil Rights
If you believe you have been treated unfairly or your rights have not been respected due to your
r•ace, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, you should
call the Department of Health and Human Set�vices' Ofiice for Civil Rights at 1-800-368-1019
or TTY 1-800-537-7697, or call your local Office for Civil Rights.
Is it about something else?
If you believe you have been treated unfairly or your rights have not been respected, and it's not
about discrimination, you can get help dealing with the problem you are having:
• You can call Member Services (phone numbers are printed on the back cover of this
booklet).
You can call the State Health Insurance Assistance Program. For details about this
organization and how to contact it, go to Chapter 2, Section 3.
Or, you can call Medicare at 1-800-MEDICf1RE (1-800-633-4227), 24 hours a day, 7
days a week. TTY users should call 1-877-486-2048.
GRP 12 220 A 99 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 8: Your t�ights and responsibilities
Section 1.9 How to get more information about your rights
There at•e several places where you can get more information about your rights:
• You can call Member Services (phone numbers are printed on the back cover of this
booklet).
You can call the State Health Insurance Assistance Program. For details about this
organization and how to contact it, go to Chapter 2, Section 3.
You can contact Medicare.
You can visit the Medicare website to read or download the publication "Your
Medicare Rights & Protections." (The publication is available at:
http://www.medicare.gov/Publications/Pubs/pdf/10112.pdf.)
Or, you can call 1-800-NIEDICARE (1-800-633-4227), 24 hours a day, 7 days a
week. TTY users should call 1-877-486-2048.
SECTION 2
Section 2.1
You have some responsibilities as a member of the plan
What are your responsibilities?
Things you need to do as a member of the plan are listed below. If you have any questions,
please call Member Services (phone numbers are printed on the back cover of this booklet).
We're het•e to help.
• Get fa`niliur witli you�• coveYed seYvices and the i•ules you must follow to get these
covered setvices. Use this Evidence of Coverage booklet to lear•n u�hat is covered for you
and the rules yoza need to follow to get yottr covered ser�vices.
• Chapters 3 and 4 give the details about your medical setvices, including what is
covered, what is not covered, r•ules to follow, and what you pay.
• Chapters 5 and 6 give the details about yom� coverage for Part D prescription
drugs.
• If you laave ufty otlter heultlt insurance coverage oY pyescription drug cove�•t�ge in
addition io our pla�Z, you are rec�uit•ed to tell us. Please call Member Services to let us
know (phone numbe�°s ar•e pr�inted on the back cover• of this booklet).
• We are required to follow rules set by Medicare to make sure that you ai•e using
all of your covet�age in combination when you get your covered services from our
plan. This is called "coordination of beneiits" because it involves coordinating
the health and drug benefits you get fi•om out� plan with any other health and drug
benefits available to you. We'll help you with it. (For more infot•mation about
coordination of benefits, go to Chaptei• 1, Section 7.)
• Tell your doctor and otlze� liealtlz cat�e pt•ovides•s that you a��e eizrolled zn oacr plan.
Shotiv your plcrn r��embei°shi� ccrNd tivheneve� yo2c get yort�� rnedical care o�� Part D
�r�escy�iptzon dracgs.
GRP_12 220 A 100 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chaptet• 8: Your rights and r•esponsibilities
• Help youf� docto�s anrl otlzef� provicle�s Izelp you by giving fhem info��mution, asking
questions, and following tli��oug�i on youY crcre.
• To help your doctois and other health providers give you the best care, learn as
much as you at•e able to about your health problems and give them the
information they need about you and your health. Follow the treatment plans and
instructions that you and your doctors agree upon.
• Make sure your doctors know all of the drugs you are talcing, including over-the-
counter drugs, vitamins, and supplements.
• If you have any questions, be sure to ask. Your doctors and other health care
providers are supposed to explain things in a way you can understand. If you ask a
question and you don't understand the answer you are given, ask again.
• Be conside�ate. We expect all our membef
also expect you to act in a way that helps
hospitals, and other offices.
, to f•espect the rights of othe�� pertients. WE
the smooth r~unning of your doctor's office,
• Pay wlacct you owe. As a plcrn naember, you are f�esponsible for these perynaents:
• You must pay your plan premiums to continue being a member of our plan.
• In order to be eligible for our plan, you must have Medicare Part A and Medicare
Part B. For that reason, some plan members must pay a premium for Medicare
Part A and most plan members must pay a premium for Medicare Part B to
remain a member of the plan.
• For most of yout� medical services or drugs covered by the plan, you must pay
your share of the cost when you get the service or drug. This will be a copayment
(a fixed amount) or coinsurance (a percentage of the total cost). Chapter 4 tells
what you must pay fot� your medical services. Chapter 6 tells what you must pay
for your Part D pr�escription drugs.
• If you get any medical services or drugs that are not covered by our plan or by
other insut•ance you may have, you must pay the full cost.
• If you disagree with our decision to deny coverage for a seivice or drug,
you can make an appeal. Please see Chapter 9 of this booklet fot�
information about how to make an appeal.
• If you are f�eyaiit•ed to pay a late enrollinent pencclt��, you must pay ihe penulty to
��eniain u member of the pla�a.
• If you a�•e reyuired to pay the extra trrrtount for Puf•t D because of your yearly
zncome, you �rzzcst pay tlae extr•a anzount dif�ectly to the gove��nment to f�emain a
membef� of tlze plun.
GRP 12 220 A 101 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 8: Your rights and t•esponsibilities
• Tell us if you niove. If you crr�e going to move, it's inzportant to tell us yight cnvay. Call
Membe�� Services (phone nunzbers are py�inted on the back cover of this booklet).
• If you move outside of our plan service area, you cannot remain a member of
our plan. (Chapter 1 tells about our service area.) We can help you figure out
whether you at•e moving outside our setvice area. If you are leaving our service
area, you will have a Special Enrollment Period when you can join any Medicare
plan available in your new area. We can let you know if we have a plan in your
new area.
If you move within our service area, we still need to know so we can keep your
membership recot•d up to date and know how to contact you.
• Cull Member Se�•vices for help if you leave questiofts o�� concerns. We also welconae any
szcggestions you may have fo�° improving our plan.
• Phone numbers and calling hours for• Member Services ar�e printed on the back
cover of this booklet.
For more information on how to reach us, including our mailing address, please
see Chaptet• 2.
GRP_12 220 A 102 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
Chapter 9. What to do if you have a problem or complaint
(covera�e decisions, appeals, complaints)
�: � . : � �u�
SECTION 1
Introduction
Section 1.1
Section 1.2
What to do if you ha�e a pt•oblem or concern
What about the legal terms?
SECTION 2 You can get help from government organizations that are not connected with
ll5
Section 2.1 Where to get more information and personalized assistance
SECTION 3 To deal with your problem, which process should you use?
Section 3.1 Should you use the process for coverage decisions and appeals? Or
should you use the process for making complaints?
COVERAGE DECISIONS AND APPEALS
SECTION 4 A guide to the basics of coverage decisions and appeals
Section 4.1 Asking for coverage decisions and making appeals: the big picture
Section 4.2 How to get help when you are asking for a coverage decision or
making an appeal
Section 4.3 Which section of this chapter gives the details for �ur situation?
SECTION 5 Your medical care: How to ask for a coverage decision or make an appeal
Section 5.1 This section tells what to do if you have problems getting coverage
for medical cat�e ot� if you want us to pay you back for our share of
the cost of your care
Section 5.2 Step-by-step: How to ask for a coverage decision (how to ask our
plan to authorize or provide the medical care coverage you want)
Section 5.3 Step-by-step: How to make a Level 1 Appeal (how to ask for a
review of a medical care coverage decision made by our plan)
Section 5.4 Step-by-step: How to make a Leve12 Appeal
Section 5.5 What if you are asking us to pay you for our share of a bill you
have received for� medical care?
SECTION 6 Your Part D prescription drugs: How to ask for a coverage decision or make
an appeal
Section 6.1
Section 6.2
Section 6.3
This section tells you what to do if you have problems getting a
Part D drug or you want us to pay you back for a Part D drug
What is an exception?
Important things to know about asking for exceptions
GRP 12 220 A 103 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna Medicat�eSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
Section 6.4 Step-by-step: How to ask for a coverage decision, including an
exception
Section 6.5 Step-by-step: How to make a Level 1 Appeal
review of a coverage decision made by our plan)
Section 6.6 Step-by-step: How to make a Level 2 Appeal
(how to ask for a
SECTION 7 How to ask us to cover a longer inpatient hospital stay if you think the doctor
is discharging you too soon
Section 7.1 During your inpatient hospital stay, you will get a written notice
fi•om Medicare that tells about your rights
Section 7.2 Step-by-step: How to make a Level 1 Appeal to change your
hospital discharge date
Section 7.3 Step-by-step: How to make a Level 2 Appeal to change your
hospital discharge date
Section 7.4 What if you miss the deadline for making your Level 1 Appeal?
SECTION 8 How to ask us to keep covering certain medical services if you think your
coverage is ending too soon
Section 8.1 This sectio� is crbout thYee services onZv.• Home health care, skilled
nursing facility care, and Comprehensive Outpatient Rehabilitation
Facility (CORF) services
Section 8.2 We wi11 tell you in advance when your coverage will be ending
Section 8.3 Step-by-step: How to make a Level 1 Appeal to have our plan
cover your care for a longer time
Section 8.4 Step-by-step: How to make a Level 2 Appeal to
cover your care for� a longer time
Section 8.5 What if you miss the deadline for making your Level
have our plan
1 Appeal?
SECTION 9 Tal�ing your appeal to Level 3 and beyond
Section 9.1 Levels of Appeal 3, 4, and 5 for Medical Setvice Appeals
Section 9.2 Levels of Appeal3, 4, and 5 for Part D Drug Appeals
MAKING COMPLAINTS
SECTION 10 How to make a complaint about quality of care, waiting times, customer
service, or other concerns
Section 10.1 VJhat kinds of problems are handled by the complaint process?
Section 10.2 The formal name for "making a conlplaint" is "filing a grievance"
Section 10.3 Step-by-step: Making a complaint
Section 10.4 You can also make complaints about quality of care to the Quality
Improvement Organization
Section 10.5 You can also tell Medicare about your complaint
GRP_12 220 A 104 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
BACKGROUND
SECTION 1 Introduction
Section 1.1 What to do if you have a problem or concern
This chapter explains two types of processes for handling problems and concerns:
• For some types of problems, you need to use the process for coverage decisions and
making appeals.
• For• other types of problems, you need to use the process for making complaints.
Both of these processes have been approved by Medicare. To ensure fairness and prompt
handling of yom� problems, each process has a set of rules, procedures, and deadlines that must
be fo Ilowed by us and by you.
Which one do you use? That depends on the type of problem you are having. The guide in
Section 3 will help you identify the right process to use.
Section 1.2 What about the legal terms?
There are technical legal terms for some of the rules, procedures, and types of deadlines
explained in this chapter. Many of these terms are unfamiliar to most people and can be hard to
understand.
To keep things simple, this chapter explains the legal rules and procedures using simpler words
in place of certain legal terms. For example, this chapter generally says "making a complaint"
rather than "filing a grievance," "coverage decision" rather than "organization determination" or
"coverage determination," and "Independent Review Organization" instead of "Independent
Review Entity." It also uses abbreviations as little as possible.
However, it can be helpful — and sometimes quite important — for you to know the correct legal
terms for the situation you are in. Knowing which terms to use will help you communicate more
clearly and accut�ately when you are dealing with your problem and get the right help or
information for your situation. To help you know which terms to use, we include legal terms
when we give the details for handling specific types of situations.
GRP 12 220 A 105 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
SECTION 2 You can get help from government organizations that are
not connected with us
Section 2.1 Where to get more information and personalized assistance
Sometimes it can be confusing to start or follow through the process for dealing with a problem.
This can be especially true if you do not feel well or have limited energy. Other titnes, you may
not have the knowledge you need to take the next step.
Get help from an independent government organization
We are always available to help you. But in soine situations you may also want help ot• guidance
fi•om someone who is not connected with us. You can always contact your State Health
Insurance Assistance Program (SHIP). This government program has trained counselors in
every state. The program is not connected with us or with any insurance company or health plan.
The counselors at this program can help you understand which process you should use to handle
a pt•oblem you are having. They can also answer your questions, give you mot•e information, and
offer guidance on what to do.
The services of SHIP counselots are free. You will fmd phone numbers in Addendum A of this
booklet.
You can also get help and information from Medicare
For more information and help in handling a problem, you can also contact Medicare. Here are
two ways to get information directly from Medicare:
• You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY
users should call 1-877-486-2048.
• You can visit the Medicare website (http://www.medicare.gov).
SECTION 3 To deal with your problem, which process should you use?
Section 3.1 Should you use the process for coverage decisions and appeals? Or
should you use the process for making complaints?
If you have a pr•oblem or concern, you only need to read the parts of this chapter that apply to
your situation. The guide that follows will help.
GRP_12 220 A 106 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
To figure out which part of this chapter will help
with your specific problem or concern, START
HERE
Is your problem or concern about your benefits or coverage?
(This includes problems about whether• particular medical care or prescription drugs are covered
or not, the way in which they are covered, and problems related to payment for medical care or
prescription drugs.)
Yes.
My problem is about benefits or coverage
Go on to the next section of this chapter,
Section 4, "A guide to the basics of
coverage decisions and making appeals."
No.
My problem is not about benefits ar coverage.
Skip ahead to Section 10 at the end of this
chapter: "How to make a complaint about
quality of care, waiting times, customer
service or other concerns."
COVERAGE DECISIONS AND APPEALS
SECTION 4
Section 4.1
A guide to the basics of coverage decisions and appeals
Asking for coverage decisions and making appeals: the big picture
The process for coverage decisions and making appeals deals with problems related to your
benefits and coverage for medical services and prescription drugs, including problems related to
payment. This is the process you use for issues such as whether something is covered or not and
the way in which something is covered.
Asking for coverage decisions
A coverage decision is a decision we make about your benefits and coverage or about the atnount
we will pay for your medical services or drugs. For example, your plan network doctor makes a
(favorable) coverage decision for you whenever you receive medical care fi•om him or her or if
your network doctor refers you to a medical specialist. You or your doctor can also contact us
and aslc for a coverage decision if your doctor is unsure whether we will cover a particular
medical service or refuses to provide medical care you think that you need. In other wor•ds, if you
want to know if we will cover a medical service before you receive it, you can ask us to make a
coverage decision for you.
We are making a coverage decision for you whenever we decide what is covered for you and
how much we pay. In some cases we might decide a setvice or drug is not covered or is no
longer covered by Medicare for you. If you disagree with this coverage decision, you can make
an appeal.
GRP 12 220 A 107 HMO EOGwith RY (Y2013)
2013 Evidence of Coverage for Aetna Medicat�eSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
Malang an appeal
If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the
decision. An appeal is a formal way of asking us to review and change a coverage decision we
have made.
When you make an appeal, we review the coverage decision we have made to check to see if we
were following all of the rules properly. Your appeal is handled by different reviewers than those
who made the original unfavorable decision. When we have completed the review, we give you
our decision.
If we say no to all or part of your Level 1 Appeal, you can go on to a Leve12 Appeal. The Level
2 Appeal is conducted by an independent organization that is not connected to us. (In some
situations, your case will be automatically sent to the independent organization for a Level 2
AppeaL If this happens, we will let you know. In other situations, you will need to ask for a
Level 2 Appeal.) If you are not satisfied with the decision at the Level 2 Appeal, you may be
able to continue through several more levels of appeal.
Section 4.2 How to get help when you are asking for a coverage decision or
making an appeal
Would you like some help? Here are resources you may wish to use if you decide to ask for any
kind of coverage decision or appeal a decision:
• You can call us at Metnber Services (phone numbers are printed on the back cover of
this booklet).
To get free help from an independent organization that is not connected with our plan,
contact your State Health Insurance Assistance Program (see Section 2 of this chapter).
• Your doctor or other provider can make a request for you. For medical care, a doctor
can malce a request for you. Your doctot� can request a coverage decision or a Level 1
appeal on your behalf. If your appeal is denied at Levei 1, it will be automatically
forwarded to Level 2. To request any Appeal after Levei 2, your doctor must be
appointed as your representative. For Pat•t D prescription drugs, yout• doctor or other
prescriber can request a coverage determination or a Level 1 or 2 appeal on your behalf.
To request any appeal after Level 2, your doctor or other pt•escriber must be appointed as
your representative.
• You can ask someone to act on your behaif. If you want to, you can name another
person to act for you as your "representative" to ask for a coverage decision or make an
appeal.
• Thet�e rnay be someone who is already legally authorized to act as your
representative under state law.
GRP_12 220 A 108 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
� Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
�• If�you want a fi�iend, relative, your doctor or other provider, or other person to be
your representative, call Member• Seivices (phone numbers are printed on the
back cover of this booklet) and aslc for the "Appointment of Representative"
form. (The form is also available on Medicare's website at
http://www.cros.hhs.gov/crosforms/downloads/cros1696.pdf.) The form gives
that person per•mission to act on your• behalf. It must be signed by you and by the
person who you would like to act on youS• behalf. You must give us a copy of the
signed form.
• You may also download the form on our website at:
http://www.aetnamedicat•e.com/help_and_resout�ces/downloadable forms 2012.js
p?tab=4 and select the "CMS Appointment ofRepresentative Form" located in the
Exception, Appeals and Grievances Forms section of the site.
• You also have the right to hire a lawyer to act for you. You may contact your own
lawyer, or get the name of a lawyer from your local bar association or other referral
service. There are also groups that will give you free legal services if you qualify.
However, you are not required to hire a lawyer to ask for any kind of coverage
decision or appeal a decision.
Section 4.3 Which section of this chapter gives the details for vour situation?
There are four diffet�ent types of situations that involve coverage decisions and appeals. Since
each situation has different rules and deadlines, we give the details for each one in a separate
section:
• Section 5 of this chapter: "Your medical cat•e: How to ask for a coverage decision or
make an appeal"
• Section 6 of this chapter: "Your Part D prescription drugs: How to ask for a coverage
decision or make an appeal"
• Section 7 of this chapter: "How to ask us to cover a longer inpatient hospital stay if you
think the doctor is discharging you too soon"
• Section 8 of this chapter: "How to ask us to lceep covering certain medical services if you
thinlc your coverage is ending too soon" (Applies to these services only: home health
care, skilled nut•sing facility care, and Comprehensive Outpatient Rehabilitation Facility
(CORF) services)
If you're not sure which section you should be using, please call Member Services (phone
numbers are printed on the back cover of this booklet). You can also get help or information
from government organizations such as your State Health Insurance Assistance Progt•am
(Addendum A at the back of this booklet has the phone numbers for this progt�am).
GRP 12 220 A 109 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna Medicat�eSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
SECTION 5
Your medical care: How to ask for a coverage decision or
make an appeal
� Have you read Section 4 of this chapter (A gzcide to "the basics " of covercrge decisions
and appeals)? If not, you may want to read it before you start this section.
Section 5.1
This section tells what to do if you have problems getting coverage for
medical care or if you want us to pay you back for our share of the
cost of your care
This section is about your benefits for medical care and services (but does not cover Part D
dtugs, please see Section 6 for Part D drug appeals). These beneiits are described in the Medical
Benefits Chart (Summary of Copayments/Coinsurance) included with this Evidence of Coverage.
To keep things simple, we generally refer to "medical care coverage" or "medical care" in the
rest of this section, instead of repeating "medical care or treatment or services" every time.
This section tells what you can do if you are in any of the five following situations:
1. You are not getting certain medical care you want, and you believe that this care is
covered by our plan.
2. Our plan will not approve the medical care your doctor or other medical provider wants
to give you, and you believe that this care is covered by the plan.
3
You have t•eceived medical care or services that you believe should be covered by the
plan, but we have said we will not pay for this care.
4. You have t�eceived and paid for medical care or services that you believe should be
covered by the plan, and you want to ask our plan to t•eimburse you for this care.
5. You are being told that coverage for cer�tain medical care you have been getting that we
previously approved will be reduced or• stopped, and you believe that reducing or
stopping this care could harm your health.
• NOTE: If the coverage that will be stopped is for hospital care, home health
care, skilled nursing facility care, or Comprehensive Outpatient
Rehabilitation Facility (CORF) services, you need to read a separate section of
this chaptet� because special rules apply to these types of cat•e. Here's what to read
in those situations:
• Chapter 9, Section 7: How to ask us to cover• a longer inpatient hospital
stay if yozc think the doctor is clischarging yozc too soon.
• Chapter 9, Section 8: How to ask irs to kee� covering certain medreal
services if yozc think your• coverage is ending too soon. This section is
abo�rt three setvices only: home health care, skilled nursing facility care,
and Comprehensive Outpatient Rehabilitation Facility (CORF) services.
GRP_12 220 A 110 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna Medicat•eSM Plan (HMO)
Chapter 9: What to do if you have a pt�oblem ot� complaint (coverage decisions, appeals,
complaints)
• For all other situations that involve being told that medical care you have been
getting will be stopped, use this section (Section 5) as your guide for what to do.
Which of these situations are you in? �
� �
If you are in this situation: This is what you can do: �
� ,M���-��_�- �_���� -� �.� .� ,,�� -� � ,Y ._� . ._rv._._ � �m� �� :���w�-���w� �.��� � ��,:.r. rr� u_.. =� �>.
� Do you want to fmd out whether we will You can ask us to make a coverage decision �
� cover the medical care or services you want? for you. r
Go to the next section of this chapter, �
Section 5.2. �
� �� _ ��=��» ,��-�� _��
- ��_�. �.��-v� v,��u � w_--=_�,��- �.� ���. w,� . ��-_-�-�_��:�.,��.— -��
� Have we already told you that we will not You can make an appeal. (This means you �
� cover or pay for a medical service in the way are aslcing us to reconsider.) �
. that you want it to be covered or paid for?
F Skip ahead to Section 5.3 of this chaptel
-. � _,�.��r-_.� . _.r«� . _-- �-�,;�,-��P������ �, , _�����_ .�,� �_ rr � �� _.,�_�� ��,� � �_._, ..
Do you want to ask us to pay you back for You can send us the bill. �
medical care ot� services you have already
received and paid for? Skip ahead to Section 5.5 of this chapter.
Section 5.2 Step-by-step: How to ask for a coverage decision (how to ask our plan
to authorize or provide the medical care coverage you want)
Legal When a coverage decision involves yout• medical care, it is called an "organization
Terms determination."
Step 1: You ask our plan to make a coverage decision on the medical care you are
requesting. If your health requires a quick response, you should ask us to make a"fast coverage
decision."
Legal A"fast coverage decision" is called an "expedited determination."
Terms
How to reqziest coverage foN the medical care you want
• Start by calling, writing, or faxing out� plan to inake your request for us to provide
coverage for the medical care you want. You, your doctor, or your representative can do
this.
• For the details on how to contact us, go to Chapter 2, Section 1 and look for the section
called, How to contact zts �a�hen you crre asking fot• a cover�age decision about yoz���
naedical care.
GRP 12 220 A 1 ll HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problern or complaint (coverage decisions, appeals,
complaints)
Gener�ally we use the standard de�rdlines foY giving yoac our• decision
When we give you our decision, we will use the "standard" deadlines unless we have agreed to
use the "fast" deadlines. A standard coverage decision means we will give you an answer
within 14 days after we receive your request.
• However, we can take up to 14 more calendar days if you ask for more time, or if we
need information (such as medical records from out-of-network providers) that may
benefit you. If we decide to take extra days to rnake the decision, we will tell you in
writing.
• If you believe we should not take extra days, you can file a"fast complaint" about our
decision to take extra days. When you file a fast complaint, we will give you an answer to
your complaint within 24 hours. (The process for making a complaint is different from
the process for coverage decisions and appeals. For more information about the pt•ocess
for making complaints, including fast complaints, see Section 10 of this chapter.)
If yoatN health re yzcires it, ask us to give you a` fast coverage decision "
• A fast coverage decision means we will answer within 72 hours.
• However, we can take up to 14 more calendar days if we find that some
information that may benefit you is missing (such as medical records from out-of-
network providers), or if you need time to get information to us for the review. If
we decide to take extra days, we will tell you in writing.
• If you believe we should not take extra days, you can file a"fast complaint" aboltt
our decision to take extra days. (For more information about the process for
rnaking cornplaints, including fast complaints, see Section 10 of this chapter.) We
wi11 call you as soon as we make the decision.
• To get a fast coverage decision, you must meet two requirements:
• You can get a fast coverage decision only if you are asking for coverage for
medical care you have not yet y�eceived. (You cannot get a fast coverage decision
if your request is about payment for medical care you have already received.)
• You can get a fast coverage decision only if using the standai�d deadlines could
cazrse seriozcs ha��f�z to yozrr health or hztrt yoZcr nbility to fitnction.
If your doctor tells us that your health requires a"fast coverage decision," we will
automaticaliy agree to give you a fast coverage decision.
• If you ask for a fast coverage decision on your own, without your doctor's support, we
will decide whether your health requires that we give you a fast coverage decision.
• If we decide that your medical condition does not meet the requirements for a fast
coverage decision, we will send you a letter that says so (and we will use the
standard deadlines instead).
GRP_12 220 A 112 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for� Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem ot• complaint (coverage decisions, appeals,
complaints)
• This lettet• will tell you that if your doctor asks for the fast coverage decision, we
will automatically give a fast coverage decision.
• The letter will also tell how you can file a"fast complaint" about our decision to
give you a standard coverage decision instead of the fast coverage decision you
requested. (For more information about the process for making complaints,
including fast complaints, see Section 10 of this chapter.)
Step 2: We consider your request for medical care coverage and give you our answer.
Deadlines for• a`fast" coverage decision
• Generally, for a fast coverage decision, we will give you our answer within 72 hours.
• As explained above, we can take up to 14 more calendar days under certain
circumstances. If we decide to take extra days to make the coverage decision, we
will tell you in writing.
• If you believe we should not take extra days, you can file a"fast complaint" about
our decision to take extra days. When you file a fast complaint, we will give you
an answer to your complaint within 24 hours. (For more information about the
process for making complaints, including fast complaints, see Section 10 of this
chapter.)
• If we do not give you our answer within 72 hours (or if there is an extended time
period, by the end of that period), you have the right to appeal. Section 5.3 below
tells how to make an appeal.
• If our answer is yes to part or all of vvhat you requested, we must authorize or pt•ovide
the medical care coverage we have agreed to provide within 72 hours after we received
your request. If we extended the time needed to make our coverage decision, we will
provide the coverage by the end of that extended period.
• If our answer is no to part or all of what you requested, we will send you a detailed
wt�itten explanation as to why we said no.
Deacllines fot� cr "standar�d" coveYage decision
• Generaily, for a standard coverage decision, we will give you our answer within 14 days
of receiving your request.
• We can take up to 14 mor•e calendar days ("an extended time period") under
certain circumstances. If we decide to take extra days to make the covet•age
decision, we will tell you in writing.
• If you believe we should not take extra days, you can file a"fast complaint" about
our decision to take extra days. When you file a fast complaint, we will give you
an answer to your complaint within 24 hours. (For more information about the
GRP 12 220 A 113 HMO EOGwith RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
process for making complaints, including fast complaints, see Section 10 of this
chapter.)
• If we do not give you our answer within 14 days (or if there is an extended titne
pet•iod, by the end of that pet�iod), you have the right to appeal. Section 5.3 below
tells how to make an appeal.
• If our answer is yes to part or all of what you requested, we must authot�ize or provide
the coverage we have agreed to provide within 14 days after we received your request. If
we extended the time needed to make our coverage decision, we will provide the
coverage by the end of that extended period.
If our answer is no to part or all of what you requested, we will send you a written
stateinent that explains why we said no.
Step 3: If we say no to your request for coverage for medical care, you decide if you want to
make an appeal.
• If we say no, you have the right to ask us to reconsider — and perhaps change — this
decision by making an appeal. Making an appeal means making another tty to get the
medical care coverage you want.
• If you decide to make an appeal, it means you are going on to Level 1 of the appeals
process (see Section 5.3 below).
Section 5.3 Step-by-step: How to make a Level 1 Appeal (how to ask for a review
of a medical care coverage decision made by out• plan)
Legal An appeal to the plan about a medical care coverage decision is called a plan
Terms "reconsideration."
Sten 1; You contact us and make your appeal. If your health requires a quick t•esponse, you
must ask far a"fast appeal."
What to do
• To start your appeal, you, your doctor, or your representative, must contact us. For
details on how to reach us for any purpose related to your appeal, go to Chapter 2,
Section 1 look for section called, How to contcrct zrs ��hen yozr are making an crp�eal
about your mea'ical car�e.
• If you are asking for a standard appeal, make your standard appeal in writing by
submitting a signed request.
• If you have someone appealing our decision for you other than your doctor, your
appeal must include an Appointment of Representative form authorizing this
person to represent you. To get the form, call Member Seivices (phone numbers
are printed on the back cover of this booklet) and ask for the "Appointment of
GRP_12 220 A 114 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a pt•oblem or complaint (coverage decisions, appeals,
complaints)
�: _ � � . . � _ �
Representative" form. It is also available on Medicare's website at
http:Uwww.cros.hhs.gov/crosforms/downloads/cros1696.pdf. While we can accept
an appeal request without the form, we cannot complete our t•eview until we
receive it. If we do not t�eceive the form within 44 days after receiving your appeal
request (our deadline for making a decision on your appeal), your appeal request
will be sent to the Independent Review Organization for dismissal.
• If you are asking for a fast appeal, make your appeal in writing or call us at the
phone number shown in Chapter 2, Section 1(How to contact us when you are making an
appeal about your meclical ccrre).
• You must make your appeal request within 60 calendar days fi•om the date on the
written notice we sent to tell you our answer to your request for a coverage decision. If
you miss this deadline and ha�e a good reason for missing it, we may give you more time
to make your appeal. Examples of good cause for missing the deadline may include if
you had a serious illness that prevented you from contacting us or if we provided you
with incorrect or incomplete information about the deadline for requesting an appeal.
• You can ask for a copy of the information regarding your medical decision and add
more information to support your appeal.
• You have the right to ask us for a copy of the information regarding your appeal.
We are allowed to charge a fee for copying and sending this information to you.
If you wish, you and your doctor may give us additional information to support
your appeal.
If your health NeqatiiNes zt, ask for a`fast crppeal "(you can nzake a reqitest by calling us)
Legal A"fast appeal" is also called an "expedited reconsideration."
Terms
• If you are appealing a decision we made about coverage for care you have not yet
received, you and/or your doctor will need to decide if you need a"fast appeal."
• The requirements and pi�ocedures for getting a"fast appeal" are the same as those for
getting a"fast coverage decision." To ask for a fast appeal, follow the instructions for
asking for a fast coverage decision. (These instructions are given earlier in this section.)
• If your doctor tells us that your health t•equi�•es a"fast appeal," we will give you a fast
appeal.
Step 2: We consider your appeal aud we give you our answer.
• When our plan is reviewing your appeal, we take another careful look at all of the
information about your request for coverage of inedical care. We check to see if we were
following all the r�ules when we said no to your request.
GRP 12 220 A ll5 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or• complaint (coverage decisions, appeals,
complaints)
• We will gather more information if we need it. We may contact you or your doctor to get
mor•e information.
Deadlines for a `fast" appeal
• When we at•e using the fast deadlines, we must give you out� answer within 72 hours
after we receive your appeal. We will give you our answer sooner if yout• health
requires us to do so.
• However, if you ask for more tirne, or if we need to gather more information that
may benefit you, we can take up to 14 more calendar days. If we decide to take
extra days to make the decision, we will tell you in writing.
• If we do not give you an answer within 72 hours (ot• by the end of the extended
time period if we took extra days), we at•e required to automatically send your
request on to Level 2 of the appeals process, where it will be reviewed by an
independent organization. Later in this section, we tell you about this organization
and explain what happens at Leve12 of the appeals process.
• If our answer is yes to part or all of what you requested, we must authorize or provide
the coverage we have agreed to provide within 72 hours after we receive your appeal.
• If our answer is no to part or all of what you requested, we will send you a written
denial notice informing you that we have autoinatically sent your appeal to the
Independent Review Organization for a Leve12 Appeal.
Deadlines for a "standrerd" appeul
• If we are using the standard deadlines, we must give you our answer within 30 calendar
days after we receive your appeal if your appeal is about coverage for services you ha�e
not yet received. We will give you our decision sooner if your health condition requires
us to.
• However, if you ask for rnore time, or if we need to gather more inforination that
may benefit you, we can take up to 14 more calendar days.
• If you believe we should not take extra days, you can file a"fast complaint" about
out� decision to take extra days. When you file a fast complaint, we will give you
an answer to your complaint within 24 hours. (For more information about the
process for tnaking complaints, including fast complaints, see Section 10 of this
chapter.)
• If we do not give you an answer by the deadline above (or by the end of the
extended time pet•iod if we took extra days), we at�e requi��ed to send your request
on to Leve12 of the appeals process, where it will be reviewed by an independent
outside organization. Latei• in this section, we tell about this review organization
and explain what happens at Leve12 of the appeals process.
GRP_12 220 A 116 HMO EOC—with Rac (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
ri , _� . _ �_ . . . ... . __ , .
• If our answer is yes to part or all of what you requested, we must authorize or provide
the coverage we have agreed to provide within 30 days after we receive your appeal.
• If our answer is no to part or all of what you requested, we will send you a written
denial notice informing you that we have automatically sent your appeal to the
Independent Review Organization for a Level 2 Appeal.
Sten 3; If our plan says no to part or all of your appeal, your case will automaticully be sent
on to the next level of the appeals process.
• To make sure we were following all the rules when we said no to your appeal, we are
required to send your appeal to the "Independent Review Organization." When we
do this, it means that your appeal is going on to the next level of the appeals process,
which is Leve12.
Section 5.4 Step-by-step: How to make a Leve12 Appeal
If we say no to your Level 1 Appeal, your case will automatically be sent on to the neXt level of
the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews
the decision we made when we said no to your first appeal. This organization decides whether
the decision we made should be changed.
Legal The forinal name for the "Independent Review Organization" is the "Independent
Terms Review Entity." It is sometimes called the "IRE."
Step 1: The Independent Review Organization reviews your appeal.
• The Independent Review Organization is an independent organization that is hired
by Medicare. This organization is not connected with us and it is not a government
agency. This organization is a company chosen by Medicare to handle the job of being
the Independent Review Organization. Medicare oversees its work.
• We will send the information about your appeal to this organization. This information is
called yout� "case file." You have the right to ask us for a copy of your case file.
You have a right to give the Independent Review Organization additional information to
support your appeal.
• Reviewet�s at the Independent Review Organization will take a careful look at all of the
information related to your appeal.
If you had a` fast" appeal at Level 1, you lvill also have a`fast" appeal at Level 2
• If you had a fast appeal to our plan at Level 1, you will automatically
appeal at Level 2. The review organization must give you an answer to
Appeal within 72 hours of when it receives yout� appeal.
receive a fast
your Level 2
GRP 12 220 A 117 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna Medicat�eSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
• However, if the Independent Review Organization needs to gather more infot•mation that
may benefit you, it can take up to 14 more calendar days.
If you had a"stcznda�d " appeal at Level 1, you will also have a"standard" appeal at Level 2
• If you had a standard appeal to our plan at Level 1, you will automatically receive a
standard appeal at Level 2. The review organization inust give you an answer to your
Leve12 Appeal within 30 calendar days of when it t•eceives your appeal.
However, if the Independent Review Organization needs to gather more information that
may benefit you, it can take up to 14 more calendar days.
Step 2; The Independent Review Organization gives you their answer.
The Independent Review Organization will tell you its decision in writing and explain the
reasons for it.
• If the review organization says yes to part or all of what you requested, we must
authorize the medical care coverage within 72 hours or provide the setvice within 14
calendar days after we receive the decision fi•om the review organization.
• If this organization says no to part or all of your appeal, it means they agree with us
that your request (or part of your request) for coverage for medical care should not be
approved. (This is called "upholding the decision." It is also called "tt.uning down your
appeal.")
• The written notice you get fi•om the Independent Review Organization will tell
you the dollar amount that must be in dispute to continue with the appeals
process. For example, to continue and make another• appeal at Level 3, the dollar
value of the rnedical care coverage you are requesting must meet a certain
minimum. If the dollar value of the covet�age you are requesting is too low, you
cannot make another appeal, which means that the decision at Leve12 is final.
Step 3: If your case meets the
appeal further.
• There are three additional
levels of appeal).
requiremeuts, you choose whether you want to take your
levels in the appeals process after Level 2(for a total of five
• If your Level 2 Appeal is turned down and you meet the requu�ernents to continue with
the appeals process, you must decide whether you want to go on to Level 3 and make a
third appeal. The details on how to do this are in the written notice you got after your
Leve12 Appeal.
• The Level 3 Appeal is handled by an adtninistrative law judge. Section 9 in this chapter
tells rnore about Levels 3, 4, and 5 of the appeals process.
GRP_l2 220 A 118 HMO EOC—with R�c (Y2013)
2013 Evidence of Coverage for Aetna Medicar•eSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
Section 5.5 What if you are asking us to pay you for our share of a bill you have
received for medical care?
If you want to ask us for payment for medical care, start by reading Chapter 7 of this booklet:
Asking us to pay our share of a bill you have received for covered n�edical sef-vices or drzcgs.
Chapter 7 describes the situations in which you may need to ask for reimbursement or to pay a
bill you have received from a provider. It also tells how to send us the paperwork that asks us for
payment.
Asking for reimbursement is asking for a coverage decision from us
If you send us the paperwork that asks for reimbursement, you are asking us to make a coverage
decision (for more information about coverage decisions, see Section 4.1 of this chapter). To
make this covet�age decision, we will check to see if the medical care you paid for is a covered
service (see Chapter 4: Medical Benefits Chart (what is covered and what yoa� pay)). We will
also check to see if you followed all the r�ules for using your coverage for medical care (these
rules are given in Chapter 3 of this booklet: Using the plan's coverage for your medical
services).
We will say yes or no to your request
• If the medical care you paid for is covered and you followed all the rules, we will send
you the payment for our share of the cost of your medical care within 60 calendar days
after we receive your request. Or, if you haven't paid for the services, we will send the
payment directly to the provider. (When we send the payment, it's the same as saying yes
to your request for a coverage decision.)
• If the medical care is not covered, or you did not follow all the rules, we will not send
payment. Instead, we will send you a letter that says we will not pay for the services and
the reasons why in detail. (When we turn down your request for payment, it's the same as
saying no to your request for a coverage decision.)
What if you ask for payment and we say that we will not pay?
If you do not agree with our decision to turn you down, you can inake an appeaL If you make
an appeal, it means you are asking us to change the coverage decision we made when we turned
down your request fot• payment.
To make this appeal, follow the process for appeals that we describe in part 5.3 of this
section. Go to this part for step-by-step instt•uctions. When you are following these instructions,
please note:
• If you make an appeal for t•eimbuisement, we must give you om� answer within 60
calendar days after we receive your appeal. (If you are asking us to pay you back for
medical care you have ah•eady received and paid fot� yourself, you are not allowed to ask
for a fast appeal.)
If the Independent Review Organization reverses our decision to deny payment, we must
send the payment you have requested to you or to the provider within 30 calendar• days. If
GRP 12 220 A 119 HMO EOC—with R�c (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a probiem or complaint (coverage decisions, appeals,
complaints)
the answer to your appeal is yes at any �stage of the appeals process a$er• Level 2, we
must send the payment you requested to you or to the provider within 60 calendar days.
SECTION 6
Your Part D prescription drugs: How to ask for a coverage
decision or make an appeal
� ' Have you read Section 4 of this chapter (A gzcide to "the basics" of coverage
clecisions and appeals)? If not, you may want to read it before you start this section.
Section 6.1
This section tells you what to do if you have problems getting a Part D
drug or you want us to pay you back for a Part D drug
Your benefits as a member of our plan include coverage for many prescription drugs. Please
refer to our plan's List of Cover°ed Drargs (Fornzulary). To be covered, the dt•ug must be used for
a medically accepted indication. (A "medically accepted indication" is a use of the drug that is
either approved by the Food and Dt•ug Administi�ation or supported by certain reference books.
See Chapter 5, Section 4 for more inforrnation about a medically accepted indication.)
• This section is about your Part D drugs only. To keep things simple, we generally say
"drug" in the rest of this section, instead of repeating "covered outpatient prescription
dtug" or "Part D drug" every time.
• For details about what we mean by Part D dr•ugs, the List of Cover�ed Dr•ugs (Formzrlary),
rules and restrictions on coverage, and cost information, see Chapter 5(Using oz�r�lan's
coverage for yozcY Part D prescNi�tion drugs) and Chapter 6(What you pay for� your� Part
D prescription dr�ugs).
Part D coverage decisions and appeals
As discussed in Section 4 of this chapter, a coverage decision is a decision we make about your
benefits and coverage or about the amount we will pay for your drugs.
Legal An initial coverage decision about your Part D drugs is called a"coverage
Terms determination."
Here are exatnples of coverage decisions you ask us to make about your Part D drugs:
• You ask us to malce an exception, including:
• Asking us to cover a Part D drug that is not on the plan's List of Covered Dyugs
(Forinulary)
Asking us to waive a t•estriction on the plan's coverage for a drug (such as limits
on the amount of the drug you can get)
Asking to pay a lower cost-sharing amount for a covered non-preferred drug
GRP_12 220 A 120 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
• You ask us whether a drug is covered for you and whether you� satisfy any applicable
coverage rules. (For example, when your drug is on the plan's List of Covei�ed Drugs
(Fo�°�riulafy) but we r•equire you to get approval from us befoi�e we will covei• it for you.)
• Please note: If your pharmacy tells you that your prescription cannot be filled as
written, you will get a written notice explaining how to contact us to ask fot� a
coverage decision.
• You ask us to pay for a prescription drug you already bought. This is a request for a
coverage decision about payment.
If you disagree with a coverage decision we have made, you can appeal our decision.
This section tells you both how to ask for coverage decisions and how to request an appeal. Use
the chart below to help you determine which part has information for your situation:
Which of these situations are you in?
Do you need a drug
that isn't on our Drug
List or need us to
waive a rule or
restriction on a drug
we cover?
You can ask us to
make an exception.
(This is a type of
coverage decision.)
Start with Section 6.2
of this chapter
Section 6.2
Do you want us to
cover a drug on our
Drug List and you
believe you meet any
plan rules or
restrictions (such as
getting appr•oval in
advance) for the drug
you need?
You can ask us for a
coverage decision.
Skip ahead to Section
6.4 of this chapter.
What is an exception?
Do you want to ask us
to pay you back for a
drug you have already
received and paid for?
You can ask us to pay
you back. (This is a
type of coverage
decision.)
Skip ahead to Section
6.4 of this chapter.
Have we already told
you that we will not
cover or pay for a
drug in the way that
you want it to be
covered or paid for?
You can make an
appeal. (This means
you are asking us to
reconsider.)
Skip ahead to Section
6.5 ofthis chapter.
If a dr�ug is not covered in the way you would like it to be covered, you can ask us to make an
"exception." An exception is a type of coverage decision. Similar to other types of coverage
decisions, if we turn down your request fot� an exception, you can appeal our decision.
When you aslc for an exception, your doctor or other� prescriber will need to explain the medical
r�easons why you need the exception approved. We will then consider your� request. Here at•e
three examples of exceptions that you or your doctor or other pY•escribet� can aslc us to make:
GRP 12 220 A � 121 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
1. Covering a Part D drug for you that is not on our List � of Cover•ed Drugs
(Fot�mulaiy). (We call it the "Drug List" for short.)
Legal Asking for coverage of a drug that is not on the Drug List is sometimes called
Terms asking for a"formulary exception."
• If we agree to make an exception and cover a drug that is not on the Dr�ug List,
you will need to pay the cost-sharing amount that applies to drugs in the
exceptions cost-sharing tier. You cannot ask for an exception to the copayment or
coinsurance amount we require you to pay for the drug.
2. Removing a restriction on our coverage for a covered drug. Thet•e ar•e extra rules or
restrictions that apply to certain drugs on our List of Covered Dr�ugs (Formulary) (for
more information, go to Chapter 5 and look for Section 5).
Legal Asking for removal of a restriction on coverage for a drug is sometimes called
Terms asking for a"formulary exception."
• The extra rules and restrictions on coverage fot� certain drugs include:
• Getting �lan approval in advance before we will agree to cover the drug
for you. (This is sometiines called "prior authorization.")
• Being required to tty cr different clyzcg first before we will agree to cover
the drug you at•e asking for. (This is sometimes called "step therapy.")
• Quantity limits. For some drugs, there are restrictions on the amount of the
drug you can have.
• If we agree to make an exception and waive a restriction for you, you can ask for
an exception to the copayment or coinsurance atnount we r•equi�•e you to pay for
the drug.
3. Changing coverage of a drug to a lower cost-sharing tier. Evety drug on our Drug List
is in one of a nutnber of cost-sharing tiers. In general, the lower the cost-sharing tier
number, the less you will pay as your share of the cost of the drug.
Legal Asking to pay a lower preferred pt•ice fot• a covered non-preferred drug is
Terms sometimes called asking for a"tiering exception."
• If your plan contains both prefet�red and non-preferred drug tiet•s, you can ask us
to make a tiering exception. If your drug is in the cost-sharing tier for non-
pt�efert•ed generic dt�ugs, you can ask us to cover it at the cost-sharing amount that
applies to preferred generic drugs. If your dt�ug is in the cost-sharing tier for non-
preferred brand name drugs, you can ask us to cover it at the cost-sharing amount
GRP_12 220 A 122 HMO EOC-with RY (Y2013)
2013 Evidence of Cover�age for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a pr•oblem or complaint (coverage decisions, appeals,
complaints)
� that applies�to preferred brand name drugs. This would lower your share of the
cost for the drug.
• You cannot ask us to change the cost-sharing tier for any drug in the specialty
drug cost-sharing tier (if applicable to your plan).
Section 6.3
Important things to know about asking for exceptions
Your doctor must tell us the medical reasons
Your doctor or other prescriber must give us a statement that explains the medical reasons for
t•equesting an exception. For a faster decision, include this medicai information from your doctor
or� other prescriber when you ask for the exception.
Typically, our Drug List includes more than one drug for treating a particular condition. These
different possibilities are called "alter•native" dt�ugs. If an alternative drug would be just as
effective as the drug you are requesting and would not cause more side effects or other health
problems, we will generally not approve your request for an exception.
We can say yes or no to your request
• If we approve your request for an exception, our approval usually is valid until the end of
the plan year. This is true as long as your doctor continues to prescribe the drug for you
and that drug continues to be safe and effective for treating your condition.
• If we say no to your t•equest for an exception, you can ask for a review of our decision by
making an appeal. Section 6.5 telis how to make an appeal if we say no.
The next section tells you how to ask for a coverage decision, including an exception.
Section 6.4 Step-by-step: How to ask for a coverage decision, including an
exception
Step 1: You ask us to make a coverage decision about the drug(s) or payment you need. If
your health requires a quick response, you must ask us to make a"fast coverage decision." You
cannot ask for a fast coverage decision if you are asking us to pay you back for a drug you
already bought.
Whcct to do
• Request the type of coverage decision you want. Start by calling, writing, or faxing us
to make your request. You, yom• representative, or your doctor (or other prescriber) can
do this. For the details, go to Chapter 2, Section 1 and look for the section called, How to
contact ars when yoz� are asking for a coveT^age decision abortt yoacr Part D prescf�iption
drugs. Or if you are asking us to pay you back for a drug, go to the section called, Where
to send a�eqZtest that asks us to pay for oZtr share of the cost for medical care or a drug
you have receivea'.
GRP 12 220 A 123 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem ot� complaint (coverage decisions, appeals,
complaints)
• You or your doctor or someone else who is acting on your behalf �can ask foi• a
coverage decision. Section 4 ofthis chapter tells how you can give written permission to
someone else to act as your representative. You can also have a lawyer act on your
behalf.
• If you want to ask us to pay you back for a drug, start by reading Chapter 7 of this
booklet: Asking us to pery our share of a bill you hcrve received for cover�ed lnedical
services or drzrgs. Chapter 7 describes the situations in which you may need to ask for
reimbursement. It also telis how to send us the paperwork that asks us to pay you back for
our share of the cost of a drug you have paid for.
• If you are requesting an exception, provide the "supporting statement." Yout• doctor
or other� prescriber must give us the medical reasons for the drug exception you are
requesting. (We call this the "supporting statement.") Your doctor or other prescriber can
fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone
and follow up by faxing or mailing a written statement if necessary. See Sections 6.2 and
6.3 for more information about eYception requests.
If youf� hec�lth �eqttiNes it, ask its to give yoaa a` fast coverage decision "
Legal A"fast coverage decision" is called an "expedited coverage determination."
Terms
• When we give you our decision, we wi11 use the "standard" deadlines unless we have
agreed to use the "fast" deadlines. A standard coverage decision means we will give you
an allswer within 72 hours after we receive your doctor's statement. A fast covet•age
decision means we will answer within 24 hours.
• To get a fast coverage decisiou, you must meet two requirements:
• You can get a fast coverage decision only if you are asking for a drug yoz� have
not yet r�eceived. (You cannot get a fast coverage decision if you are asking us to
pay you back for a drug you have ah�eady bought.)
• You can get a fast coverage decision only if using the standard deadlines could
cause se3°ioZts harm to yoz�f° health oi� hzar�t youN nbility to ficnctzon.
• If your doctor or other prescriber tells us that your health requires a"fast coverage
decision," we will automatically agree to give you a fast coverage decision.
• If you ask for a fast coverage decision on your own (without your doctor's or other
prescriber's support), we will decide whether your health requu•es that we give you a fast
coverage decision.
• If we decide that your medical condition does not meet the r•equu�ements for a fast
coverage decision, we will send you a letter that says so (and we will use the
standal•d deadlines instead).
GRP_12 220 A 124 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
• This letter will tell you that if your doctor or• other prescriber asks for the fast
coverage decision, we will automatically give a fast coverage decision.
• The letter will also tell how you can file a complaint about our decision to give
you a standard coverage decision instead of the fast coverage decision you
requested. It tells how to file a"fast" complaint, which means you would get our
answer to your complaint within 24 hours. (The process for making a complaint is
different fi•om the process for coverage decisions and appeals. For more
inforrnation about the process for making complaints, see Section 10 of this
chapter.)
Step 2; We consider your request and we give you our answer.
Decrdlines fof� a`fi�st" coverage decision
• If we are using the fast deadlines, we must give you our answer within 24 hours.
• Generally, this means within 24 hours after we receive your request. If you are
requesting an exception, we will give you our answer within 24 hours after� we
receive your doctor's statement supporting your r•equest. We will give you our
answer sooner if your health r•equires us to.
• If we do not meet this deadline, we are required to send your request on to Leve12
of the appeals process, where it will be reviewed by an independent outside
organization. Later in this section, we tell about this review organization and
explain what happens at Appeal Leve12.
• If our answer is yes to part or all of what you requested, we must provide the
coverage we have agreed to provide within 24 hours after we receive your request or
doctor's statement supporting your request.
• If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no.
Deadlines for a"standard" coverage decision about a drug you have not yet receivecl
• If we are using the standard deadlines, we must give you our answer within 72 hours.
• Generally, this means within 72 hout•s after we t•eceive your request. If you are
requesting an exception, we will give you our answer within 72 hours after we
receive your doctor's statement supporting your request. We will give you our
answer sooner if your health requires us to.
• If we do not meet this deadline, we are required to send your• t•equest on to Level 2
of the appeals process, whet�e it will be reviewed by an independent organization.
Later in this section, we tell about this review organization and explain what
happens at Appeal Leve12.
GRP 12 220 A 125 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
• If our answer is yes to part or all of what you requested —
• If we appt�ove your request for covet�age, we must provide the coverage we have
agreed to provide within 72 hours after we receive your request or doctor's
statement supporting your request.
• If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no.
Deadlines for a"standard" coverage decision abozct paynaent for a dNug yozc have already
bought
• We must give you our answer within 14 calenciar days after we receive yout� request.
• If we do not meet this deadline, we are required to send your request on to Leve12
of the appeals pt•ocess, where it will be reviewed by an independent organization.
Later in this section, we tell about this review organization and explain what
happens at Appeal Level 2.
• If our answer is yes to part or all of what you requested, we are also required to make
payment to you within 14 calendar days after we receive your request.
If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no.
Step 3: If we say no to your coverage request, you decide if you want to malce an appeal.
• If we say no, you have the right to request an appeal. Requesting an appeal means asking
us to reconsider — and possibly change — the decision we made.
Section 6.5 Step-by-step: How to make a Level 1 Appeal (how to ask for a review
of a coverage decision made by our plan)
Legal An appeal to the plan about a Par•t D drug coverage decision is called a plan
Terms "redetermination."
Step 1: You contact us and make your Level 1 Appeal. If your health requires a quick
response, you must ask for a"fast appeal."
What to do
• To start your appeal, you (or your representative or your doctor or other
prescriber) must contact us.
• Fot• details on how to t�each us by phone, fax, or mail for any purpose related to
your appeal, go to Chapter 2, Section 1, and look for the section called, How to
contact oiar plan when you are making an appeal about your Part D prescription
d��zags.
If you are aslung for a standard appeal, make your appeal by submitting a written
request.
GRP_12 220 A 126 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
• If you are asking for a fast appeal, you may make your appeal in writing or you may
call us at the phone number shown in Chapter 2, Section 1(How to contact our plan
when you are making an appeal about your part D prescription drugs).
• You must make your appeal request within 60 calendar days from the date on the
written notice we sent to tell you our answer to your request for a coverage decision. If
you miss this deadline and have a good reason for missing it, we may give you more time
to make your appeal. Examples of good cause for missing the deadline may include if
you had a serious illness that prevented you fi•om contacting us or if we provided you
with incorrect or incomplete information about the deadline for requesting an appeal.
• You can ask for a copy of the information in your appeal and add more
information.
• You have the right to ask us for a copy of the infor•mation regarding your appeal.
We are allowed to charge a fee for copying and sending this infoi•mation to you.
• If you wish, you and your doctor or other prescriber may give us additional
information to support your appeal.
If your health requires it, askfor cz `fast appeal "
Legal A"fast appeal" is also called an "expedited redetermination."
Terms
• If you are appealing a decision we made about a drug you have not yet received, you and
your doctor or other prescriber will need to decide if you need a"fast appeal."
• The requu•einents for getting a"fast appeal" at•e the same as those for getting a"fast
coverage decision" in Section 6.4 of this chapter.
Step 2: Our plan considers your appeal and we give you our answer.
• When we are reviewing your appeal, we take another careful look at all of the
information about your coverage request. We check to see if we were following all the
t�ules when we said no to your request. We may contact you or your� doctor or other
prescriber to get mor•e information.
Decrdlines foy� a `fast" appeal
• If we af•e using the fast deadlines, we must give you our answer within 72 hours after
we receive your appeal. We will give you our answer sooner if your health requires it.
• If we do not give you an answer within 72 hours, we are required to send your
request on to Level 2 of the appeals process, where it will be reviewed by an
Independent Review Organization. Later in this section, we tell about this review
organization and explain what happens at Level 2 of the appeals pl•ocess.
GRP_12_220_A
127
HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
• If our answer is yes to part or all of what you requested, we must provide the
coverage we have agreed to provide within 72 hours after we receive your appeal.
• If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no and how to appeal our decision.
Deac�lines for a "stayt.dard" appeul
• If we are using the standard deadlines, we must give you our answer within 7 calendar
days after we receive your appeal. We will give you out� decision sooner if you have not
received the drug yet and your health condition requires us to do so. If you believe your
health requires it, you should ask for a"fast" appeal.
• If we do not give you a decision within 7 calendar days, we are required to send
your request on to Leve12 of the appeals process, where it will be reviewed by an
Independent Review Organization. Later in this section, we tell about this review
organization and explain what happens at Leve12 of the appeals process.
• If our answer is yes to part or all of what you requested —
• If we approve a request for coverage, we must provide the coverage we have
agreed to provide as quickly as your health requires, but no later than 7 calendar
days after we receive your appeal.
• If we approve a request to pay you back for a drug you already bought, we ar�e
required to send payment to you within 30 calendar days a$er we receive your
appeal request.
• If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no and how to appeal our decision.
Step 3: If we say no to your appeal, you decide if you want to continue with the appeals
process and make ayaother appeal.
• If we say no to your appeal, you then choose whether to accept this decision or continue
by making another appeal.
• If you decide to make another appeal, it means your appeal is going on to Leve12
of the appeals process (see below).
Section 6.6 Step-by-step: How to make a Leve12 Appeal
If we say no to yout� appeal, you then choose whether to accept this decision or• continue by
making another appeaL If you decide to go on to a Level 2 Appeal, the Independent Review
Organization reviews the decision we made when we said no to yom• fu•st appeal. This
organization decides whether the decision we made should be changed.
Legal The formal name for the "Independent Review Organization" is the "Independent
Terms Review Entity." It is sometimes called the "IRE."
GRP_12 220 A 128 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna Medicat�eSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
Step 1: To make a Level 2 Appeal, you must contact the Independent Review Organization
and ask for a review of your case.
• If we say no to your Level 1 Appeal, the written notice we send you will include
instructions on how to malce a Level 2 Appeal with the Independent Review
Organization. These instructions will tell who can make this Level 2 Appeal, what
deadlines you must follow, and how to reach the t�eview organization.
• When you make an appeal to the Independent Review Organization, we will send the
information we have about your appeal to this organization. This information is called
your "case file." You have the right to ask us for a copy of your case file.
• You have a right to give the Independent Review Organization additional information to
support your appeal.
Step 2: The Independent Review Organization does a review of your appeal and gives you
an answer.
• The Independent Review Organization is an independent organization that is hired
by Medicare. This organization is not connected with us and it is not a government
agency. This organization is a company chosen by Medicare to review our decisions
about your Part D benefits with us.
• Reviewers at the Independent Review Organization will take a careful look at all of the
information related to your appeal. The organization will tell you its decision in writing
and explain the reasons for it.
Deadlines foy� `fast" appeal at Level 2
• If your health requires it, ask the Independent Review Organization for a"fast appeal."
• If the review organization agrees to give you a"fast appeal," the review organization
must give you an answer to your Level 2 Appeal within 72 hours after it receives your
appeal request.
• If the Independent Review Organization says yes to part or all of what you
requested, we must provide the drug coverage that was approved by the review
organization within 24 hours a$er we receive the decision fi�om the review organization.
Decrdlines fo�° "siundaf�d" uppeal at Level 2
• If you have a standard appeal at Level 2, the review organization must give you an
answer to your Leve12 Appeal within 7 caleudar days after it receives your� appeal.
• If the Independent Review Organization says yes to part or all of what you
requested —
• If the Independent Review Organization approves a t�equest fot� coverage, we must
provide the drug coverage that was approved by the t•eview organization within
72 hours after we receive the decision from the review organization.
GRP 12 220 A 129 HMO EOC-with Rx (Y2013)
2013 Evidence of Covet•age for Aetna Medicat•eSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
• If the Independent Review Organization approves a request to pay you back for a
drug you already bought, we are requu�ed to send payment to you within 30
calendar days a$er we receive the decision from the review organization.
What if the review organization says no to your appeal?
If this organization says no to your� appeal, it means the organization agrees with our decision not
to approve your request. (This is called "upholding the decision." It is also called "turning down
your appeal.")
To continue and make anothet• appeal at Level 3, the dollar value of the drug coverage you are
requesting must meet a miniinum amottnt. If the dollar value of the coverage you are requesting
is too low, you cannot make another appeal and the decision at Level 2 is final. The notice you
get from the Independent Review Oiganization will tell you the dollaY• value that must be in
dispute to continue with the appeals process.
Sten 3: If the dollar value of the coverage you are requesting meets the requirement, you
choose whether you want to take your appeal further.
• There are three additional levels in the appeals process after Level 2(fol• a total of five
levels of appeal).
• If your Level 2 Appeal is turned down and you meet the requirements to continue with
the appeals process, you must decide whether� you want to go on to Level 3 and make a
third appeaL If you decide to make a third appeal, the details on how to do this are in the
written notice you got after your second appeal.
• The Level 3 Appeal is handled by an administrative law judge. Section 9 in this chapter
tells more about Levels 3, 4, and 5 of the appeals process.
SECTION 7 How to ask us to cover a longer inpatient hospital stay if
you think the doctor is discharging you too soon
When you at•e admitted to a hospital, you have the right to get all of yotir covered hospita]
services that are necessaiy to diagnose and tt•eat yotu� illness or injuiy. For more infor•mation
about our coverage for your hospital care, including any limitations on this coverage, see Chapter
4 of this booklet: Medical Benefrts Chai�t (tivhat is cove�°ed and what yort pay).
During your hospital stay, youi� doctor and the hospital staff will be working with you to prepare
for the day when you will leave the hospital. They will also help arrange for cat�e you may need
after you lea�e.
• The day you leave the hospital is called your "clischarge clate." Out� plan's coverage of
your hospital stay ends on this date.
• When your discharge date has been decided, yout� doctor or the hospital staff will let you
know.
GRP_12 220 A 130 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
• If you think you are being asked to leave the hospital too soon, you can ask for a longel•
hospital stay and your request wi11 be considet•ed. This section tells you how to ask.
Section 7.1 During your inpatient hospital stay, you will get a written notice from
Medicare that tells about your rights
During your hospital stay, you will be given a written notice called An In�portant Message fr�om
Medicare about Your Rights. Everyone with Medicare gets a copy of this notice whenever they
are admitted to a hospital. Sorneone at the hospital (for exainple, a caseworker or nuise) must
give it to you within two days after you are admitted. If you do not get the notice, ask any
hospital employee for it. If you need help, please call Member Services (phone numbers are
printed on the back cover of this booklet). You can also call 1-800-MEDICARE (1-800-633-
4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
1. Read this notice carefully and ask questions if you don't understand it. It tells you
about your rights as a hospital patient, including:
• Your right to receive Medicare-covered setvices during and a$er your hospital
stay, as ordered by your doctor. This includes the right to know what these
services are, who will pay for them, and where you can get them.
• Yom• right to be involved in any decisions about your hospital stay, and know
who will pay for it.
• Where to report any concerns you have about quality of your hospital care.
• Your right to appeal your discharge decision if you think you are being
discharged from the hospitai too soon.
Legal The written notice from Medicare tells you how you can "request an immediate
Terms review." Requesting an immediate review is a formal, legal way to ask for a delay in
your discharge date so that we will cover your hospital care for a longer time.
(Section 7.2 below tells you how you can request an immediate review.)
2. You must sign the written notice to show that you received it and understand your
rights.
• You or someone who is acting on your behalf must sign the notice. (Section 4 of
this chapter tells how you can give written permission to someone else to act as
yout• representative.)
• Signing the notice shows only that you have received the information about your
rights. The notice does not give your discharge date (your doctor or hospital staff
will tell you your discharge date). Signing the notice does not mean you are
agreeing on a discharge date.
GRP 12 220 A 131 HNIO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chaptet• 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
.. . ..
3. Keep your copy of the signed notice so you will have the information about making an
appeal (ot� reporting a concern about quality of care) handy if you need it.
• If you sign the notice more than 2 days before the day you leave the hospital, you
will get another copy before you are scheduled to be discharged.
• To look at a copy of this notice in advance, you can call Member Services (phone
numbet�s at•e printed on the back cover ofthis booklet) or 1-800 MEDICt1RE (1-
800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-
2048. You can also see it online at http://www.cros.govlBNI/12 Hospital
DischargeAppealNotices. asp.
Section 7.2
Step-by-step: How to make a Level 1 Appeal to change your hospital
discharge date
If you want to ask for your inpatient hospital set�vices to be covered by us for a longer time, you
will need to use the appeals process to make this request. Before you start, understand what you
need to do and what the deadiines aee.
• Follow the process. Each step in the first two levels of the appeals process is explained
below.
• Meet the deadlines. The deadlines are important. Be sure that you understand and follow
the deadlines that apply to things you must do.
• Ask for help if you need it. If you have questions or need help at any time, please call
Member Services (phone numbets are printed on the back cover of this booklet). Or call
your State Health Insurance Assistance Program, a government or•ganization that
provides personalized assistance (see Section 2 of this chapter).
During a Level 1 Appeal, the Quality Improvement Organization reviews your appeal. It
checks to see if your planned discharge date is medically appropriate for• you.
Step 1: Contact the Quality Improvement Organization in your state and ask for a"fast
review" of your hospital discharge. You must act quickly.
Legal A"fast review" is also cailed an "immediate review."
Terms
What is the Qzralzty Improvement Organization?
• This organization is a gt•oup of doctors and other health care professionals who at•e paid
by the federal governtnent. These eYperts are not pat�t of our plan. This organization is
paid by Medicare to check on and help improve the quality of care for people with
Medicare. This includes reviewing hospital discharge dates for people with Medicare.
GRP_12 220 A 132 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
How can you contact this organization?
• The written notice you received (An In2portcrnt Message fi�on2 Medicaf•e About Your�
Rights) tells you how to reach this organization. (Or find the name, address, and phone
number of the Quality Improvement Organization for your state in Addendum A at the
back of this booklet.)
• Act quickly:
• To make your appeal, you must contact the Quality Improvement Organization before
you leave the hospital and no later than your planned discharge date. (Your "planned
discharge date" is the date that has been set for you to leave the hospital.)
• If you meet this deadline, you are allowed to stay in the hospital after your
discharge date without paying for it while you wait to get the decision on your
appeal from the Quality Improvement Organization.
• If you do not meet this deadline, and you decide to stay in the hospital after your
planned discharge date, you n�ay have to pay all of the costs for hospital care you
receive after your planned discharge date.
• If you miss the deadline for contacting the Quality Improvement Organization about your
appeal, you can make your appeal directly to our plan instead. For details about this other
way to make your appeal, see Section 7.4.
Ask foJ• a ` fast �•eview ":
• You must ask the Quality Improvement Organization for a"fast review" of your
discharge. Asking for a"fast review" means you at•e asking for the organization to use the
"fast" deadlines for an appeal instead of using the standard deadlines.
Legal A"fast review" is also called an "immediate review" or an "expedited review."
Terms
Step 2; The Quality Improvement Organization conducts an independent review of your
case.
What happens dzaf�ing this review?
• Health pt•ofessionals at the Quality Improvement Organization (we will call them "the
reviewers" for shoi•t) will ask you (or your representative) why you believe coverage for
the services should continue. You don't have to prepare anything in wt�iting, but you may
do so if you wish.
• The reviewers will also look at your medical information, talk with your doctor, and
review infot•mation that the hospital and we have given to them.
• By noon of the day a$er the reviewers informed om� plan of your appeal, you will also get
a written notice that gives your planned discharge date and e�plains in detail the reasons
GRP 12 220 A 133 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a probiem or complaint (coverage decisions, appeals,
complaints)
why your doctor, the hospital, and we think it is right (medically appropriate) for you to
be discharged on that date.
Legal This written explanation is called the "Detailed Notice of Discharge." You can get
Terms a sample of this notice by calling Member Services (phone numbers are printed on
the back covet� of this booklet) or 1-800-MEDICARE (1-800-633-4227, 24 hours a
day, 7 days a week. TTY users should call 1-877-486-2048.) Or you can see a
sample notice online at http:Uwww.cros.hhs.govBNI/
Step 3: Within one full day after it has all the needed information, the Quality
Improvement Organization will give you its answer to your appeal.
What happens if the crnstiver is yes?
• If the review organization says yes to your appeal, we must keep providing your
covered inpatient hospital services for as long as these services are medicaily
necessary.
• You will have to keep paying youi• share of the costs (such as deductibles or copayments,
if these apply). In addition, there may be limitations on your covered hospital setvices.
(See Chapter 4 of this booklet).
What hcrppens if the crnswer is no?
• If the review organization says no to your appeal, they are saying that your planned
discharge date is medically appropr�iate. If this happens, our coverage for your inpatient
hospital services will end at noon on the day after the Quality Improveinent
Organization gives you its answer to your ap�eal.
• If the t�eview organization says no to your appeal and you decide to stay in the hospital,
then you may have to pay the full cost of hospital care you receive after noon on the day
after t1�e Quality Improvement Oiganization gives you its answer to your appeal.
Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make another
appeal.
• If the Quality Improvement Organization has turned down your appeal, and you stay in
the hospital after your planned discharge date, then you can make another appeal. Making
another appeal means you are going on to "Leve12" of the appeals process.
Section 7.3 Step-by-step: How to make a Level 2 Appeal to change your hospital
discharge date
If tl�e Quality Irnprovement Organization has turned down your appeal, and you stay in the
hospital after your planned discharge date, then you can make a Level 2 Appeal. During a Level
2 Appeal, you ask the Quality Improvement Organization to take another look at the decision
they made on yout� fir�st appeaL If we turn down your Level 2 Appeal, you may have to pay the
full cost for your stay a$er your planned discharge date.
GRP_12 220 A 134 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a pr•oblem or complaint (coverage decisions, appeals,
complaints)
Here are the steps for Leve12 of the appeal process:
SteF 1; You contact the Quality Improvement Organization again and ask for another
review.
• You must ask for this review within 60 calendar days a$er the day when the Quality
Improvement Organization said no to yout� Level 1 AppeaL You can ask for this review
only if you stayed in the hospital after the date that your coverage for the care ended.
Step 2: The Quality Improvement Organization does a second review of your situation.
• Reviewers at the Quality Improvement Or�ganization will take another careful look at all
of the information related to your appeal.
Step 3: Within 14 calendar days, the Quality Improvement Organization reviewers will
decide on your appeal and tell you their decision.
If the review organization says yes:
• We must reimburse you for our share of the costs of hospital cat•e you have received
since noon on the day after the date yout• first appeal was turned down by the Quality
Improvement Organization. We must continue providing coverage for your inpatient
hospital care for as long as it is medically necessary.
• You must continue to pay your share of the costs and coverage limitations may apply.
If the review orgatzization says no:
• It means they agree with the decision they made on your Level 1 Appeal and will not
change it.
• The notice you get will tell you in writing what you can do if you wish to continue with
the review pt•ocess. It will give you the details about how to go on to the next level of
appeal, which is handled by a judge.
Step 4: If the answer is no, you will need to decide whether you want to take your appeal
further by going on to Level 3.
• There are three additional levels in the appeals process after Level 2(for a total of five
levels of appeal). If the review organization turns down your Level 2 Appeal, you can
choose whether to accept that decision or whether to go on to Level 3 and make another
appeal. At Leve13, your appeal is reviewed by a judge.
• Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.
GRP 12 220 A 135 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a pr•oblem ot• complaint (coverage decisions, appeals,
complaints)
Section 7.4 What if you miss the deadline for making your Level 1 Appeal?
You can appeal to us instead
As explained above in Section 7.2, you must act quickly to contact the Quality Improvement
Organization to start yout� fn•st appeal of your hospital discharge. ("Quickly" means before you
leave the hospital and no later than your planned discharge date). If you miss the deadline for•
contacting this organization, there is another way to make your appeal.
If you use this other way of making your appeal, the first two levels of appeal ar�e differ•ent.
Step-by-Step: How to make a Level 1 Alternt[te Appeal
If you miss the deadline for contacting the Quality Improvement Organization, you can make an
appeal to us, asking for a"fast review." A fast review is an appeal that uses the fast deadlines
instead of the standard deadlines.
Legal A"fast" review (or "fast appeal") is also called an "expedited appeal".
Terms
Step 1: Contact us and ask for a"fast review."
• For details on how to contact our plan, go to Chapter 2, Section 1 and look for the section
called, Ho�t� to contact oicr� plan when you aNe making an appeal about yoirr na�edical
care.
• Be sure to ask for a"fast review." This means you are asking us to give you an answer
using the "fast" deadlines t•ather than the "standard" deadlines.
Sten 2: We do a"fast" review of your planned discharge date, checking to see if it was
medically appropriate.
• During this review, we take a look at all of the infortnation about your hospital stay. We
check to see if your planned discharge date was medically appropriate. We will check to
see if the decision about when you should leave the hospital was fair and followed all the
rules.
• In this situation, we will use the "fast" deadlines rather than the standard deadlines for
giving you the answer to this review.
Step 3; We give you our decision within 72 hours after you ask for a"fast review" ("fast
appeal").
• If vve say yes to your fast appeal, it means we have agreed with you that you still need
to be in the hospital after the discharge date, and will keep providing your covered
inpatient hospital set�vices for as long as it is medically necessary. It also means that we
have agreed to reimburse you for our share of the costs of care you have received since
the date when we said your coverage would end. (You must pay your sl�are of the costs
and there may be covet�age limitations that apply.)
GRP_12 220 A 136 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem ot• complaint (coverage decisions, appeals,
complaints)
. �. . � _ -- __ ..
• If we say no to your fast appeal, we are saying that your planned discharge date was
medically appropriate. Our coverage for your inpatient hospital services ends as of the
day we said coverage would end.
• If you stayed in the hospital after your planned discharge date, then you may
have to pay the full cost of hospital care you received after the planned discharge
date.
Step 4: If we say �zo to your fast appeal, your case will uutomatically be sent on to the next
level of the appeals process.
• To make sure we were following all the rules when we said no to your fast appeal, we
are required to send your appeal to the "Independent Review Organization." When
we do this, it means that you are auto»aatically going on to Level 2 of the appeals
process.
Step-by-Step: How to make a Level 2 Altet•nrrte Appeal
If we say no to your Level 1 Appeal, your case will automntically be sent on to the next level of
the appeals process. During the Leve12 Appeal, the Independent Review Organization reviews
the decision we made when we said no to your "fast appeal." This organization decides whether
the decision we made should be changed.
Legal The formal name for the "Independent Review Organization" is the "Independent
Terms Review Entitv." It is sometimes called the "IRE."
Sten 1: We will automatically forward your case to the Independent Review Organization.
• We are requu•ed to send the information for your Level 2 Appeal to the Independent
Review Organization within 24 hours of when we tell you that we are saying no to your
first appeal. (If you think we are not meeting this deadline or other deadlines, you can
make a complaint. The complaint process is different from the appeal process. Section 10
of this chapter tells how to make a complaint.)
Step 2; The Independent Review Organization does a"fast review" of your appeal. The
reviewers give you an answer within 72 hours.
• The Independent Review Organization is an iudependent organization that is hired
by Medicare. This organization is not connected with out• plan and it is not a govermnent
agency. This organization is a company chosen by Medicare to handle the job of being
the Independent Review Organization. Medicare oversees its work.
• Reviewers at the Independent Review Organization will take a careful look at all of the
information related to your appeal of your hospital discharge.
• If this organization says yes to your appeal, then we must reimburse you (pay you
back) for our share of the costs of hospital care you have received since the date of your
planned discharge. We must also continue the plan's coverage of your inpatient hospital
services for as long as it is medically necessary. You must continue to pay your share of
GRP 12 220 A 137 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (cover�age decisions, appeals,
complaints)
the costs. If there are coverage limitations, these could limit how much we would
reimburse or how long we would continue to cover your services.
• If this organization says no to your appeal, it means they agree with us that your
planned hospital dischar•ge date was medically appropr�iate.
• The notice you get from the Independent Review Organization will tell you in
writing what you can do if you wish to contitlue with the review process. It will
give you the details about how to go on to a Level 3 Appeal, which is handled by
a judge.
Step 3: If the Independent Review Organization turns down your appeal, you choose
whether you want to take your appeal further.
• There are three additional levels in the appeals process after Level 2(for a total of five
levels of appeal). If reviewers say no to yout• Level 2 Appeal, you decide whether to
accept their decision or go on to Level 3 and make a third appeal.
• Section 9 in this chapter te11s more about Levels 3, 4, and 5 of the appeals process.
SECTION 8 How to ask us to keep covering certain medical services if
you think your coverage is ending too soon
Section 8.1 This section is about three seyvices onlv:
nursing facility care, and Comprehensive
Facility (CORF) services
This section is about the following types of care only:
• Home health care services you at�e getting.
Home heaith care, skilled
Outpatient Rehabilitation
• Skilled nursing care you are getting as a patient in a skilled nut•sing facility. (To learn
about requirements for being considered a"skilled nutsing facility," see Chapter 12,
Definitions of in�poytant tivords.)
• Rehabilitation care you are getting as an outpatient at a Medicare-approved
Comprehensive Outpatient Rehabilitation Facility (CORF). Usually, this means you at•e
getting treatrnent for an illness or accident, or you are recovering from a major operation.
(Fot• more inforination about this type of facility, see Chapter 12, Definitions of ii�iportant
�a�o��ds.)
When you are getting any of these types of care, you ha�e the right to keep getting your covered
services for that type of care for as long as the care is needed to diagnose and treat your illness or
injury. For tnore information on your covered services, including your share of the cost and any
limitations to coverage that may apply, see the Medical Benefits Chart included with this
booklet.
GRP_12 220 A 138 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem ot• complaint (coverage decisions, appeals,
complaints)
When we decide it is time to stop covering any of the�three types of care for you, we are requu�ed
to tell you in advance. When your coverage for that care ends, we �t�ill stop paying ozrr shar�e of
the cost for� you�• cai�e.
If you think we are ending the coverage of your care too soon, you can appeal our decision.
This section tells you how to ask for an appeal.
Section 8.2
We will tell you in advance when your coverage will be ending
1. You receive a notice in writing. At least two days before our plan is going to stop
covering your care, the agency or facility that is providing your care will give you a letter
or notice.
• The written notice tells you the date when we will stop covering the care for you.
� The written notice also tells what you can do if you want to ask our plan to
change this decision
longer period of time.
about when to end your care, and keep covering it for a
Legal In telling you what you can do, the written notice is telling how you can request a
Terms "fast-track appeal." Requesting a fast-track appeal is a formal, legal way to request
a change to our covet•age decision about when to stop your care. (Section 8.3 below
tells how you can request a fast-track appeal.)
Legal The written notice is called the "Notice of Medicare Non-Coverage." To get a
Terms sample copy, call Member Services (phone numbers are printed on the back cover of
this booklet) or 1-800-MEDICIIRE (1-800-633-4227), 24 hours a day, 7 days a
week. (TTY users should call 1-877-486-2048.) Or see a copy online at
http://www.cros.hhs.govBNI/
2. You must sign the written notice to show that you received it.
• You or someone who is acting on your behalf must sign
tells how you can give written permission to someone
representative.)
the notice. (Section 4
else to act as your
• Signing the notice shows only that you have received the information about when
your coverage will stop. Signing it does not mean you agree with the plan that
it's time to stop getting the care.
Section 8.3 Step-by-step: How to make a Level 1 Appeal to have our plan cover
your care for a longer time
If you want to ask us to cover your care for a longer period of time, you will need to use the
appeals process to make this request. Before you start, understand what you need to do and what
the deadlines are.
GRP 12 220 A 139 HNfO EOC-with Rx (Y2013)
2013 Evidence of Coverage foi• Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a pt•oblem oi• complaint (coverage decisions, appeals,
complaints)
• Follow the process. Each step in the first two levels of the appeals process is explained
below.
• Meet the deadlines. The deadlines are important. Be sure that you understand and follow
the deadlines that apply to things you must do. Thet•e are also deadlines our plan must
follow. (If you think we are not meeting our deadlines, you can file a complaint. Section
10 of this chapter tells you how to file a complaint.)
• Ask for help if you need it. If you have questions or need help at any time, please call
Member Services (phone numbers are printed on the back cover of this booklet). Or call
your State Health Insurance Assistance Program, a government organization that
provides personalized assistance (see Section 2 of this chapter).
During a Level 1 Appeal, the Quality Improvement Organization reviews your appeal and
decides whether to change the decision made by our plan.
Step 1: Make your Level 1 Appeal: contact the Quality Improvement Organization in your
state and ask for a review. You must act quickly.
What is the Qzcality Inapf�ovement Organization?
• This organization is a group of doctors and other health care experts who are paid by the
federal government. These experts are not part of our plan. They check on the quality of
care received by people with Medicare and review plan decisions about when it's time to
stop covering certain kinds of inedical care.
Hotiv can you contact this organization?
• The written notice you received tells you how to
name, address, and phone number of the Quality
state in Addendum A at the back of this booklet.)
t�each this organization. (Or find the
Improvement Organization for your
What should yozr ask for?
• Ask this organization to do an independent t•eview of whether it is medically appt•opriate
for us to end coverage for your medical services.
Youf° deadline fo� contacting this orgctnization.
• You must contact the Quality Improvernent Organization to start your appeal no later
than noon of the dcry after� yozr �°eceive the lvritten notice telling you tivhen we will stop
coverzng your care.
• If you miss the deadline for contacting the Quality Improvement Organizatioll about yout�
appeal, you can malce your appeal di�•ectly to us instead. For details about this other way
to make your appeal, see Section 8.5.
GRP_12 220 A 140 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
Step 2: The Quality Improvement Organization conducts an independent review of your
case.
What happens du�ing this Neview?
• Health professionals at the Quality Improvement Organization (we will call them "the
reviewers" for shot•t) will ask you (or your representative) why you believe coverage for
the ser•vices should continue. You don't have to prepare anything in writing, but you may
do so if you wish.
• The review organization will also look at your medical infot•mation, talk with your
doctor, and review information that our plan has given to them.
• By the end of the day the reviewers informed us of your appeal, and you will also get a
written notice from us that explains in detail our reasons for• ending our coverage for your
services.
Legal This notice explanation is called the "Detailed Explanation of Non-Coverage."
Terms
Sten 3; Within one full day after they have all the information they need, the reviewers will
tell you their decision.
What happens if the reviewers say yes to your appeal?
• If the reviewers say yes to your appeal, then we must keep providing your covered
services for as long as it is medically necessary.
• You will have to keep paying your share ofthe costs (such as deductibles or copayments,
if these apply). In addition, there may be limitations on your covered services (see
Chapter 4 of this booklet).
What happens zf the f�evie�vers say no to you�- appeal?
• If the reviewers say no to your appeal, then your coverage will end on the date we have
told you. We will stop paying our share of the costs of this care.
• If you decide to keep getting the home health care, or skilled nursing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services after this date when
your coverage ends, then you will have to pay the full cost of this care yourself.
Step 4: If the answer to your Level 1 Appeal is no, you decicle if you want to make another
appeal.
• This first appeal you make is "Level 1" of the appeals process. If reviewels say no to
your Level 1 Appeal — and you choose to continue getting care after your coverage for
the care has ended — then you can make another appeal.
• Making another appeal means you are going on to "Leve12" of the appeals process.
GRP_12 220 A 141 HMO EOC-with Rs (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
Section 8.4
Step-by-step: How to make a Level 2 Appeal to have our plau cover
your care for a longer time
If the Quality Impi•ovement Organization has tut•ned down your appeal and you choose to
continue getting care after your coverage for the care has ended, then you can make a Level 2
Appeal. During a Leve12 Appeal, you ask the Quality Improvement Organization to take another
look at the decision they made on your first appeal. If we turn down your Level 2 Appeal, you
may have to pay the full cost for your home health care, or skilled nursing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when we said
your covet�age would end.
Here are the steps for Leve12 of the appeal process:
Step 1: You contact the Quality Improvement Organization again and ask fo1• another
review.
• You must ask for this review within 60 days after the day when the Quality
Improvement Organization said no to your Level 1 Appeal. You can ask for this review
only if you continued getting care after the date that your coverage for the care ended.
Sten 2: The Quality Improvement Organization does a second review of your situation.
• Reviewers at the Quality Improvement Organization will take another careful look at all
of the infot•mation related to your appeal.
Sten 3: Within 14 days, the Quality Improvement Organization reviewers will decide on
your appeal and tell you their decision.
What happens if the review organization scrys yes to yortr� appeal?
• We must reimburse you for our share of the costs of care you have received since the
date when we said your coverage would end. We must continue providing coverage for
the care for as long as it is medically necessary.
• You must continue to pay your share of the costs and there may be coverage limitations
that apply.
Whcrt happens if the review organization says t�o?
• It tneans they agree with the decision we made to your Level 1 Appeal and will not
change it.
• The notice you get wi11 tell you iti writuig what you cati do if you wish to continue with
the review process. It will give you the details about how to go on to the next level of
appeal, which is handled by a judge.
GRP_12 220 A 142 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (cover•age decisions, appeals,
complaints)
Step 4; If the answer is no, you will need to decide whether you want to take your appeal
further.
• There are three additional levels of appeal a$er Level 2, for a total of five levels of
appeal. If reviewers turn down your Level 2 Appeal, you can choose whether to accept
that decision or to go on to Level 3 and make another appeal. At Level 3, your appeal is
reviewed by a judge.
• Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.
Section S.5 What if you miss the deadline for making your Level 1 Appeal?
You can appeal to us instead
As explained above in Section 8.3, you must act quickly to contact the Quality Improvement
Organization to start your first appeal (within a day or two, at the most). If you miss the deadline
for contacting this organization, thet�e is another way to make your appeaL If you use this other
way of making your appeal, the first t►vo levels of appeal crre different.
Step-by-Step: How to make a Level 1 Alternate Appeal
If you miss the deadline for contacting the Quality Improvement Organization, you can make an
appeal to us, asking for a"fast review." A fast review is an appeal that uses the fast deadlines
instead of the standard deadlines.
Here are the steps for a Level 1 Alternate Appeal:
Legal A"fast" review (or "fast appeal") is also called an"expedited appeal".
Terms
Step 1: Contact our plan and ask for a"fast review."
• For details on how to contact us, go to Chapter 2, Section 1 and look for the section
called, How to contact ozcr �lan when you are making an appeal about yoz�r medical
ca�°e.
• Be sure to ask for a"fast review." This means you are asking us to give you an answer
using the "fast" deadlines rather than the "standard" deadlines.
Step 2: We do a"fast" review of the decision we made about when to end coverage for your
services.
• During this review, we take another look at all of the information about your case. We
check to see if we were following all the rules wllen we set the date for ending the plan's
coverage for services you were receiving.
• We will use the "fast" deadlines rather than the standard deadlines for giving you the
answer to this review. (Usually, if you make an appeal to our plan and ask for a"fast
t•eview," we are allowed to decide whether to agree to your request and give you a"fast
review." But in this situation, the rules require us to give you a fast response if you ask
for it.)
GRP 12 220 A 143 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
Step 3: We give you our decision within 72 hours after you asl� for a"fast review" ("fast
appeal").
• If we say yes to your fast appeal, it means we have agreed with you that you need
set�vices longer, and will keep providing your covered services for as long as it is
medically necessaty. It also means that we have agreed to r•eimburse you for our share of
the costs of care you have t•eceived since the date when we said your coverage would
end. (You must pay your share of the costs and there may be coverage limitations that
apply.)
• If we say no to your fast appeal, then your coverage will end on the date we have told
you and we will not pay after this date. We will stop paying our share of the costs of this
care.
• If you continued to get home health care, or skilled nuising facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services aftef• the date when
we said your coverage would end, then you will have to pay the full cost of this care
yourself.
Sten 4: If we say no to your fast appeal, your case will automrrticully go on to the next level
of the appeais process.
• To make sure we were following all the rules when we said no to your fast appeal, we
are required to send your appeal to the "Independent Review Organization." When
we do this, it means that you are auto»aatically going on to Level 2 of the appeals
process.
Step-by-Step: How to make a Level 2 Altet•nate Appeal
If we say no to your Level 1 Appeal, your case will az�tomatically be sent on to the next level of
the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews
the decision we made when we said no to your "fast appeal." This organization decides whethet•
the decision we made should be changed.
Legal The formal name for the "Independent Review Organization" is the "Independent
Terms Review Entity." It is sometimes calied the "IRE."
Step 1; We will automatically forward your case to the Independent Review Organization.
• We are requu�ed to send the inforination for your Level 2 Appeal to the Independent
Review Organization within 24 hours of when we tell you that we are saying no to your
fu•st appeal. (If you think we are not meeting this deadline ot• othei• deadlines, you can
make a complaint. The complaint process is different from the appeal process. Section 10
of this chapter tells how to make a complaint.)
GRP 12 220 A 144 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
SteA 2; The Independent Review Organization does a"fast review" of your appeal. The
reviewers give you an answer within 72 hours.
• The Independent Review Organization is an independent organization that is hired
by Medicare. This organization is not connected with our plan and it is not a govet•nment
agency. This organization is a company chosen by Medicare to handle the job of being
the Independent Review Organization. Medicare oversees its work.
• Reviewers at the Independent Review Organization will take a careful look at all of the
information related to your appeal.
• If this organization says yes to your appeal, then we must reimburse you (pay you
back) for our share of the costs of care you have received since the date when we said
your coverage would end. We must also continue to cover the cat•e for as long as it is
medically necessaiy. You must continue to pay your share of the costs. If there are
coverage limitations, these could limit how much we would reimburse or how long we
would continue to cover your services.
• If this organization says no to your appeal, it means they agr•ee with the decision our
plan made to your %rst appeal and will not change it.
• The notice you get from the Independent Review Organization will tell you in
writing what you can do if you wish to continue with the review process. It will
give you the details about how to go on to a Level 3 Appeal.
Step 3; If the Independent Review Organization turns down your appeal, you choose
whether you want to take your appeal further.
• There are three additional levels of appeal a$er Level 2, for a total of five levels of
appeal. If t�evieweis say no to your Leve12 Appeal, you can choose whether to accept that
decision or whether to go on to Level 3 and make another appeal. At Level 3, your appeal
is reviewed by a judge.
• Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.
SECTION 9 Taking your appeai to Leve13 and beyond
Section 9.1 Levels of Appeal3, 4, and 5 for Medical Service Appeals
This section may be appropriate for you if you have made a Level 1 Appeal and a Level 2
Appeal, and both of your appeals have been turned down.
If the dollar value of the item or medical service you have appealed ineets certain minunum
levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the
minimum level, you cannot appeal any further. If the dollar value is high enough, the written
response you receive to your Level 2 Appeal will explain who to contact and what to do to ask
for a Level 3 Appeal.
GRP 12 220 A 145 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
For most situations that involve appeals, the last tlu-ee levels of appeal work in much the same
way. Here is who handles the review of your appeal at each of these levels.
Level 3 Appeal A judge who works for the federal government will review your appeal
and give you an answer. This judge is called an "Administrative Law
Judge."
• If the Administrative Law Judge says yes to your appeal, the appeals process inay or
may not be over - We will decide whether to appeal this decision to Level 4. Unlike a
decision at Level 2(Independent Review Organization), we have the right to appeal a
Level 3 decision that is favorable to you.
• If we decide not to appeal the decision, we must authorize or provide you with the
setvice within 60 days after receiving the judge's decision.
• If we decide to appeal the decision, we will send you a copy of the Level 4
Appeal request with any accompanying documents. We may wait for the Level 4
Appeal decision before authorizing or providing the service in dispute.
• If the Administrative Law Judge says no to your appeal, the appeals process niuy or
may not be over.
• If you decide to accept this decision that turns down your appeal, the ap�eals
process is ovei•.
• If you do not want to accept the decision, you can continue to the next level of the
review pt�ocess. If the administrative law judge says no to your appeal, the notice
you get wiil tell you what to do next if you choose to continue with your appeal.
Level 4 Appeal The Medicare Appeals Council will review your appeal and give you an
answer. The Medicare Appeals Council works for the federal government.
• If the answer is yes, or if the Medicare Appeals Council denies our request to review
a favorable Level 3 Appeal decision, the appeals process mccy or m�y not be over -
We will decide whether to appeal this decision to Level 5. Unlike a decision at Level 2
(Independent Review Organization), we have the i•ight to appeal a Leve14 decision that is
favorable to you.
• If we decide not to appeal the decision, we r7iust authot�ize or provide you with the
service within 60 days after receiving the Medicare Appeals Council's decision.
• If we decide to appeal the decision, we will let you know in wt•iting.
If the ans�ver is no or if the Medicare Appeals Council denies the review request, the
appeals process muy or �nay not be over.
• If you decide to accept this decision that turns down your appeal, the appeals
process is over.
GRP 12 220 A 146 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicaresM Plan (HMO)
Chapter 9: What to do if you have a pt•oblem or complaint (coverage decisions, appeals,
complaints)
� If you do not want to accept the decision, you might be able to continue to the
• next level of the review process. If the Medicare Appeals Council says no to your
appeal, the notice you get will tell you whether the rules allow you to go on to a
Level 5 Appeal. If the rules allow you to go on, the written notice will also tell
you who to contact and what to do next if you choose to continue with your
appeal.
Level 5 Appeal A judge at the Federal District Court will review yout• a
• This is the last step of the administrative appeals process.
Section 9.2 Levels of Appeal 3, 4, and 5 for Part D Drug Appeals
This section may be appropriate for you if you have made a Level 1 Appeal and a Level 2
Appeal, and both of your appeals have been turned down.
If the dollar value of the drug you have appealed meets certain minimum levels, you may be able
to go on to additional levels of appeal. If the dollar value is less than the minimum level, you
cannot appeal any further. If the dollar value is high enough, the written response you receive to
your Leve12 Appeal will explain who to contact and what to do to ask for• a Leve13 Appeal.
For most situations that involve appeals, the last tlu•ee levels of appeal work in much the same
way. Here is who handles the review of your appeal at each of these levels.
Leve13 Appeal A judge who works for the federal government will review your appeal
and give you an answer. This judge is called an "Administrative Law
Judge."
• If the answer is yes, the appeals process is over. What you asked for in the appeal has
been approved. We must authorize or provide the drug coverage that was approved by
the Administrative Law Judge within 72 hours (24 hours for expedited appeals) or
tnake payment no later than 30 calendar days after we receive the decision.
• If the answer is no, the appeals process may or may not be over.
• If you decide to accept this decision that turns down your appeal, the appeals
process is over.
• If you do not want to accept the decision, you can continue to the next level of the
review process. If the administrative law judge says no to your appeal, the notice
you get will teli you what to do next if you choose to continue with yout• appeal.
Leve14 Appeal The Medicare Appeals Council will 1•eview your appeal and give you an
answer. The Medicare Appeals Council works for the federal government.
GRP 12 220 A 147 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (cover�age decisions, appeals,
complaints)
• If the answer is yes, the appeals process is over. What you asked for in the appeal has
been approved. We must authorize or provide the drug coverage that was a�proved by
the Medicar•e Appeals Council within 72 hours (24 hours for expedited appeals) or
make payment no later than 30 calendar days after we receive the decision.
• If the answer is no, the appeals process muy or m�ry not be over.
• If you decide to accept this decision that tut•ns down your appeal, the appeals
process is over.
• If you do not want to accept the decision, you might be able to continue to the
next level of the review process. If the Medicat•e Appeals Council says no to your
appeal or denies your request to review the appeal, the notice you get will tell you
whether the rules allow you to go on to a Level 5 Appeal. If the rules allow you to
go on, the written notice wiil also tell you who to contact and what to do next if
you choose to continue with your appeal.
Level 5 Appeal A judge at the Federal District Court will review your appeal.
• This is the last step of the appeals process.
MAKING COMPLAINTS
SECTION 10 How to make a complaint about quality of care, waiting
times, customer service, or other concerns
If your problem is about decisions related to benefits, coverage, or payment, then
? this section is not fof° you. Instead, you need to use the process for coverage
decisions and appeals. Go to Section 4 of this chapter.
Section 10.1 What kinds of problems are handled by the coinplaint process?
This section explains how to use the process for making complaints. The complaint process is
used for certain types of probletns only. This includes problems related to quality of care, waiting
times, and the customer setvice you receive. Here are exainples of the kinds of problems handled
by the complaint process.
GRP_12 220 A 148 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a p�•oblem or complaint (coverage decisions, appeals,
complaints)
If you have any of these kinds of problems,
you can "make a complaint"
Quality of your medical care
• Ar•e you unhappy with the quality of the care you have received (including care in the
hospital)?
Respecting your privacy
• Do you believe that someone did not respect your right to privacy or shared information
about you that you feel should be confidential?
Disrespect, poor customer service, or other negative behaviors
• Has someone been rude or disrespectful to you?
• Are you unhappy with how our Member• Services has treated you?
• Do you feel you are being encour�aged to leave the plan?
Waiting times
• Are you having trouble getting an appointment, or waiting too long to get it?
• Have you been kept waiting too long by doctors, pharmacists, or other health
professionals? Or by our Member Services or other staff at the plan?
• Examples include waiting too long on the phone, in the waiting room, when
getting a prescription, or in the exam t•oom.
Cleanliness
• Are you unhappy with the cleanliness or condition of a clinic, hospital, or doctor's
office?
Information you get from us
• Do you believe we have not given you a notice that we are required to give?
• Do you think written information we have given you is hard to understand?
The next page hcrs »�of�e excrmples of�ossible f•easons fot• making a con�plaznt
Possible complaints
These types of complaints are all related to the timeliness of our actions related to
coverage decisions and appeals
The process of asking for a coverage decision and making appeals is explained in sections 4-9
of this chapter�. If you are asking for a decision or making an appeal, you use that process, not
the complaint process.
However, if you have already asked us for a coverage decision or made an appeal, and you
think that we are not responding quickly enough, you can also make a complaint about our
slowness. Here are examples:
• If you have asked us to give you a"fast coverage decision" or a"fast appeal," and we
GRP 12 220 A 149 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
Possible complaints
have said we wili not, you can make a complaint.
• If you believe we are not meeting the deadlines for giving you a coverage decision or an
answer to an appeal you have made, you can make a complaint.
• When a coverage decision we made is reviewed and we are told that we rnust cover or
reimburse you for• certain medical services or drugs, there are deadlines that apply. If
you think we are not tneeting these deadlines, you can tnake a cotnplaint.
• When we do not give you a decision on time, we are required to forward your case to
the Independent Review Organization. If we do not do that within the required deadline,
you can make a coznplaint.
Section 10.2 The formal name for "making a complaint" is "filing a grievance"
Legal
Terms
• What this section calls a"complaint" is also called a"grievance."
• Another term for "making a complaint" is "filing a grievance."
• Another way to say "using the process for complaints" is "using the
for filing a
»
Section 10.3 Step-by-step: Making a complaint
Step 1: Contact us promptly — either by phone or in writing.
• Usually, calling Member Services is the iirst step. If there is anything else you need to
do, Member Seivices will let you know. Call the number on the back of your member ID
card. Hours of operation: are 8 a.m. to 6 p.m. in all time zones, Monday through Friday.
• You can submit a complaint about our plan online. To submit an online complaint go
to: http:/1www.aetnamedicare.comlplan_choices/advantage_appeals_grievances.jsp
• If you do not wish to call or submit online (or you called and were not satisfied), you
can put your complaint in writing and send it to us. If you put your complaint in
writing, we will respond to your complaint in writing.
• If you want to use this process, here's how it works:
• Send your written carnplaint (also known as a grievance) to:
Aetna Medicat•e Grievance & Appeal Unit
P.O. Box 14067
Le�ington, KY 40512
• Be sure to provide all pertinent information ot• you may also download the form
on our website at: http://www.aetnamedicare.con�/help_and_resour�ces/
downloadable_forms 2012.jsp?tab=4 and select the "Aetna Medicare Grievance
GRP 12 220 A 150 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
z, � . ,.., �.,.�. , ...:
Form" located in the Exception, Appeals and Grievances Forms section of the
site.
• The gt�ievance must be submitted within 60 days of the event or incident. Your
issue will be investigated by a grievance analyst who did not have any previous
involvement with your issue. For• written complaints, you will receive a written
notice stating the result of our review, which will be sent to you. This notice will
include a description of our understanding of your grievance, and our decision in
clear terms. We must address your grievance as quickly as your case requil�es
based on your health status, but no later than 30 days after receiving your
complaint. We may extend the time fi�ame by up to 14 days if you ask for an
extension or if we identify a need for additional information and the delay is in
your best interest.
• You also have the right to ask for a fast "expedited" grievance. An expedited or
"fast" grievance is a type of complaint that must be resolved within 24 hours from
the time you contact us. You have the right to request a"fast" grievance if you
disagree with:
• Our plan to take a 14-day e�ension on an organization determination or
reconsideration, or
• Our denial of your request to expedite an organization determination or
reconsideration for health services or
• Our denial of your request to expedite a coverage determination or
redetermination for a prescription clrug.
• The expedited/fast gi•ievance process is as follows: You or an authot•ized
representative may call, fax, or mail your complaint and mention that you want
the fast, ot• expedited, grievance process. Call 1-888-267-2637, fax your
complaint to 1-866-604-7092, or write your coinplaint and send it to the address
shown in the paragraph above. Upon receipt of the complaint, we will promptly
investigate the issue you have identified. If we agree with your complaint, we will
cancel the 14-day extension, or expedite the determination or appeal as you
originally requested. Regardless of whether we agree or not, we will notify you of
our decision by phone within 24 houTs and send written follow-up shortly
thereafter.
• Whether you call or write, you should contact Member Services right away. The
complaint must be made within 60 calendar days after you had the problem you want to
complain abou�.
• If you are making a complaint because we denied your request for a"fast coverage
decision" or a"fast appeal," we will automatically give you a"fast" complaint. If
you have a"fast" complaint, it means we will give you an answer within 24 hours.
GRP 12 220 A 151 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
Legal What this section calls a"fast complaint" is also called an "expedited grievance."
Terms
Step 2: We look into your complaiut and give you our answer.
• If possible, we will answer you right away. If you call us with a complaint, we may be
able to give you an answer on the same phone call. If your health condition requires us to
answer quickly, we will do that.
• Most complaints are answered in 30 calendar days. If we need more information and
the delay is in your best interest or if you ask for more time, we can take up to 14 more
calendar days (44 calendar days total) to answer your complaint.
• If we do not agree with some or all of your complaint or don't take responsibility for the
problem you are complaining about, we will let you know. Our response will include our
reasons for this answer. We must respond whether we agree with the complaint or not.
Section 10.4 You can also make complaints about quality of care to the Quality
Improvement Organization
You can make your complaint about the quality of care you received to us by using the step-by-
step process outlined above.
When your complaint is about qzrality of car�e, you also have two exh�a options:
• You can malce your complaint to the Quality Improvement Organization. If you
prefer, you can make your complaint about the quality of care you received directly to
this organization (without making the complaint to us).
• The Quality Improvement Organization is a group of practicing doctors and other
health care experts paid by the federal governtnent to check and iinprove the car•e
given to Medicare patients.
To find the name, address, and phone number of the Quality Improvement
Organization for your state, look in Addendum A at the back of this booklet. If
you make a complaint to this organization, we will work with them to resolve
your complaint.
• Or you can make your complaint to both at the same time. If you wish, you can make
yout� complaint about quality of care to us and also to the Quality Improvement
Organization.
Section 10.5 You can also tell Meclicare about your complaint
You can submit a complaint about our plan directly to Medicas•e. To submit a complaint to
Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx. Medicare takes your
GRP_12 220 A 152 HMO EOGwith RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
� Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
. . _. _ . _. _ _. _. .�
complaints set•iously and will use this information to help improve the quality of the Medicare
program.
If you have any other feedback or concerns, or if you feel the plan is not addressing your issue,
please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048.
GRP 12 220 A 153 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter l 0: Ending your membership in the plan
Chapter 10. Endin� vour membership in the plan
SECTION 1 Introduction
Section 1.1 This chapter focuses on ending your membet�ship in our plan
SECTION 2 When can you end your membership in our plan?
Section 2.1 You can end your membership during the Alulual Enrollment
Period
Section 2.2
You can
Advantage
limited
end your membership dur�ing the annual Medicare
Disenrollment Period, but your choices are more
Section 2.3 In certain situations, you can end your membership during a
Special Enrollment Period
Section 2.4 Where can you get more information about when you can end your
membership?
SECTION 3 How do you end your membership in our plan?
Section 3.1 Usually, you end your membership by enrolling in another plan
SECTION 4 Until your membership ends, you must keep getting your medical services
and drugs through our plan
Section 4.1 Until your membership ends, you are still a member of our plan
SECTION 5 Aetna Medicare must end your membership in the plan in certaiu situatious
Section 5.1 When must we end your membership in the plan?
Section 5.2 We cannot ask you to leave our plan for any reason related to your
health
Section 5.3 You have the right to make a complaint if we end yout•
membership in our plan
GRP_12 220 A 154 HMO EOGwith R�c (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 10: Ending your membership in the plan
SECTION 1
Section 1.1
Introduction
This chapter focuses on ending your membership in our plan
Ending your membership in our plan may be voluntary (your own choice) or involuntary (not
your own choice):
• You might leave our plan because you have decided that you u�crnt to leave.
• As a member• of an employer/union/trust group retiree plan, you may voluntat•ily
end your membership at any time. There are also certain specific times during the
year, or certain situations, when you may voluntarily end your membership in the
plan. Section 2 tells you ivhen you can end your membership in the plan. .
• The process for voluntarily ending your membership varies depending on
type of new coverage you are choosing. Section 3 tells you how to end
membetship in each situation.
what
your
• There are also limited situations where you do not choose to leave, but we are requu•ed to
end your membership. Section 5 tells you about situations when we must end your
mernbership.
If you are leaving our plan, you must continue to get your medical care and prescription drugs
through our plan until your membership ends.
It is important that you consult with your plan benefits administrator be ot•e dropping your
group retiree coverage. This is important because you may permanently lose beneiits you
currently receive under your employer or retiree group coverage if you switch plans.
SECTION 2 When can you end your membership in our plan?
Because you at�e enrolled in our plan through your former employer/unionitrust, some of the
information in this chapter does not apply to you, because you are allowed to make plan changes
at othet• times permitted by your plan sponsor. However, if you ever choose to discontinue your
gt•oup retu•ee health plan coverage, the information in this chapter will apply to you.
If your former employer/union/trust plan holds an annual Open Enrollment Period, you may be
able to make a change to your health coverage at that time. Your plan benefits administrator will
let you know when yom• Open Enrollment Period begins and ends, what plan choices are
available to you, and the effective date of coverage.
All members have the opportunity to leave the plan during the Annual Enroliment Pet•iod and
during the annual Medicare Advantage Disem•ollment Period. In certain situations, you may also
be eligible to leave the plan at other times of the year. Because of your special situation
(enrollment through your former employer/union/trust's group plan) you are eligible to end your
membership at any time through a Special Enrollment Pet•iod (see Section 2.3).
GRP 12 220 A 155 HMO EOGwith RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 10: Ending your membership in the plan
Section 2.1 You can end your membership during the general Medicare Annual
Enroliment Period
You can end your membership during the Annual Enrollment Period (also known as the
"Annual Coordinated Election Pet•iod"). This is the titne when you should review yout• health
and drug coverage and make a decision about your coverage for the upcoming year.
• When is the Annual Enrollment Period? This happens from October 15 to December
7.
• What type of plan can you switch to during the Annual Enrollment Period? During
this time, you can review your health coverage and yout• prescription drug coverage. You
can choose to lceep your current coverage or make changes to your coverage for the
upcoming year. If you decide to change to a new plan, you can choose any of the
following types of plans:
• Another Medicare health plan. (You can choose a plan that covets prescription
drugs or one that does not cover prescription drugs.)
• Original Medicare with a separate Medicare prescription drug plan.
• — or — Original Medicare without a separate Medicare prescription dt•ug plan.
• If you receive Extra Help from Medicare to pay for your prescription
drugs: If you switch to Original Medicare and do not enroll in a separate
Medicare prescription drug plan, Medicare may eru•oll you in a drug plan,
unless you have opted out of automatic enrollment.
Note: If you disenroll from Medicare presct•iption drug coverage and go without
creditable prescription drug coverage, you may need to pay a late enrollment
penalty if you join a Medicare drug plan later. ("Creditable" coverage means the
coverage is expected to pay, on average, at least as much as Medicai•e's standard
prescription drug coverage.) See Chapter 6, Section 10 for more information
about the late enrollment penalty.
• When will your membership end? Your membership will end when your new plan's
coverage begins on January 1 st.
It is important that you consult with your plan benefits administrator before dropping
your group retiree coverage. This is important because you may permanently lose
benefits you currently receive under your employer or retiree group coverage if you
switch plans.
Section 2.2 You can end your membership during the annual Medicare
Advantage Disenrollment Period, but your choices are more limited
You have the o�portunity to make one change to your health coverage dui•ing the annual
Medicare Advantage Disenrollment Period.
GRP_12 220 A 156 HMO EOGwith RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 10: Ending your membership in the plan
„�. � � .,
• When is the annual Medicare Advantage Disenrollment Period? This happens evely
year from January 1 to February 14.
• What type of plan can you switch to during the annual Medicare Advantage
Disenrollment Period? During this time, you can cancel your Medicare Advantage Plan
enrolltnent and switch to Original Medicare. Ifyou choose to switch to Original Medicare
during this period, you have until Februaty 14 to joiu a separate Medicare prescription
drug plan to add drug coverage.
• Wheu will your membership end? Your membership will end on the first day of the
month after we get yout• request to switch to Original Medicare. If you also choose to
enroll in a Medicare prescription drug plan, your membership in the drug plan will begin
the first day of the month after the drug plan gets your enrollment request.
Section 2.3
In certaiu situations, you cau end your membership during a Special
Enrollment Period
In cet•tain situations, membeis of our plan may be eligible to end their membership at other times
ofthe year. This is known as a Special Enrollment Period.
• Who is eligible for a Special Enrollment Period? If any of the following situations
apply to you, you are eligible to end your membership during a Special Enrollment
Period. These are just examples, for the full list you can contact the plan, call Medicare,
or visit the Medicare website (http://www.medicare.gov):
• Usually, when you have moved.
• If you have Medicaid.
• If you are eligible for E�tra Help with paying for your Medicare prescriptions.
• If we violate our contract with you.
• If you are getting care in an institution, such as a nursing home or long-term ca1�e
hospital.
• If you enroll in the Program ofAll-inclusive Care for the Elderly (PACE).
• If you are enrolled in an employer/union/trust gi•oup plan.
It is important that you consider your decision to disenroll from our plan carefully PRIOR
to disenrolling. Since disenrollment from our plan could affect your employer or union
health benefits, you could permanently lose your employer or union health coverage. If you
are considering disenrolling from our plan and have not done so already, please consult
with your plan benefits administrator.
• When are Special Enrollment Periods? The ent•ollment periods vary depending on your
situation.
• What can you do? To find out if you are eligible for a Special Enrollment Period, please
call Medicare at 1-800-MEDICIIRE (1-800-633-4227), 24 hours a day, 7 days a week.
TTY users call 1-877-486-2048. If you are eligible to end your membership because of a
special situation, you can choose to change both your Medicare health coverage and
prescription drug coverage. This rneans you can choose any of the following types of
plans:
GRP 12 220 A 157 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 10: Ending your membeiship in the plan
• Another Medicare health plan. (You can choose a plan that covers prescription
drugs or one that does not cover prescription drugs.)
• Original Medicare with a separate Medicare prescription drug plan.
• — o� — Original Medicare i�vithout a separate Medicare prescription drug plan.
• If you receive Extra Help from Medicare to pay for your prescription
drugs: If you switch to Original Medicare and do not enroll in a separate
Medicare pr•escr�iption dtug plan, Medicare may enr•oll you in a drug plan,
unless you have opted out of automatic enrollment.
Note: If you disenroll fi•om Medicare prescription drug coverage and go without
creditable prescr�iption drug coverage, you may need to pay a late enrollment
penalty if you join a Medicare drug plan later. ("Creditable" coverage means the
coverage is expected to pay, on average, at least as much as Medicare's standard
prescription drug coverage.) See Chapter 6, Section 10 for more information
about the late enrollment penalty.
• When will your membership end? Your inembership will usually end on the first day of
the month after we receive your request to change your plan.
Section 2.4 Where can you get more information about when you can end your
membership?
If you have any questions or would like more information on when you can end your
membership:
• You can call Member Services (phone numbers are printed on the back cover of this
booklet).
• You can find the information in the Merlicai�e & Yoa� 2013 Handbook.
• Everyone with Medicare receives a copy ofMedicare & You each fall. Those new
to Medicate receive it within a month a$et• fn•st signing up.
• You can also download a copy fi�orn the Medicat�e website
(http:Uwww.medicare.gov). Or, you can ordei• a printed copy by calling Medicat�e
at the numbei• below.
• You can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7
days a weelc. TTY users should call 1-877-486-2048.
SECTION 3 How do you end your membership in our plan?
Section 3.1 Usually, you end your membership by enrolling in another plan
Usually, to end your membership in our plan, you simply enroll in another Medicat•e plan dut�ing
one of the em�ollment periods (see Section 2 for information about the enrollment periods).
GRP_12 220 A 158 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 10: Ending your membership in the plan
.. _ ,. _
However, if you want to switch fi•om our plan to Original Medicare without a Medicare
prescription drug plan, you must aslc to be disenrolled from our plan. There are two ways you
can ask to be disenrolled:
• You can make a request in wt•iting to us. Contact Member Services if you need more
information on how to do this (phone numbers are printed on the back of your member
ID card.
• --or--You can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day,
7 days a week. TTY users should call 1-877-486-2048.
Note: If you disenroll fi•om Medicare prescription drug coverage and go without creditable
prescription drug coverage, you may need to pay a late enrollment penalty if you join a Medicare
drug plan later. ("Creditable" coverage means the coverage is expected to pay, on average, at
least as much as Medicare's standard prescription drug coverage.) See Chapter 6, Section 10 for
more information about the late enrollment penalty.
The table below explains how you should end your membership in our plan.
� If you would like to switch from our ; This is what you should do: �
plan to � �
�._�y �,��-��� ,� � _���� � ��_ �r�n�, � � � .��e ..e � w_� � - �,_�, ������
"• An individual Medicare health • Enroll in the new Medicare health �
plan. plan. �
You will automatically be disenrolled
from our plan when your new plan's �
coverage begins. "
�-,_r_ �� w� � .�,.._� _ � ,,� _� . ��_�_ _ ��� �_.��_L�.,_� �. � y . , � �
f
�• Original Medicare 1��ath a • Enroll ��in �the new Medicare �
separate Medicare prescription presci•iption drug plan.
drug plan. You will automatically be disem•olled �
fi•om our plan when your new plan's �
coverage begins. �
�� =--.u��_ � �� �_ -�� �,, �:.- �__ _ _�_ ,_� �� ��.. �.�_� ��. t ..�t�_
�� ,� � , _ .. . ... ���
,• Original Medicare without a • Send us a written reques o
separate Medicare prescription disenroll. Contact Member Services if
drug plan. you need more information on how to �
do this (phone numbers are printed on �
� Note: If you disenroll from a Medicare the back of your member ID card). �
�prescrip tion drug p lan an d go wi t hou t • You can a lso co n tac t M e d i c a r e, a t 1- ;
creditable prescription drug coverage, 800-MEDICARE (1-800-633-4227),
you may need to pay a late enrollment 24 hours a day, 7 days a weelc, and ask
penalty if you join a Medicare drug to be disenrolled. TTY users should
�plan later. See Chapter 6, Section 10 call 1-877-486-2048.
for more information about the late • You wiil be disenrolled from our plan �
enro llment penalty when your covei age m Ot igmal �
GRP 12 220 A 159 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter• 10: Ending your membershi� in the plan
If you would like to switch from our
plan to:
This is what you should do:
Medicare begins.
SECTION 4
Section 4.1
Until your membership ends, you must keep getting your
medical services and drugs through our plan
Until your membership ends, you are still a member of our plan
If you leave our plan, it may take time before your membership ends and your new Medicat•e
coverage goes into effect. (See Section 2 for information on when your new coverage begins.)
During this time, you must continue to get your tnedical cat•e and prescription drugs thr•ough out�
plan.
• You should contiuue to use our network pharmacies to get your prescriptions filled
until your membership in our plan ends. Usually, your prescription drugs are only
covered if they are filled at a network pharmacy including through our mail-order
phat•macy services.
• If you are hospitalized on the day that your membership ends, your hospital stay
will usually be covered by our plan until you are discharged (even if you at•e
discharged after your new health coverage begins).
SECTION 5 Aetna Medicare must end your membership in the plan in
certain situations
Section 5.1
When must we end your membership in the plan?
Aetna Medicare must end your membership in the plan if any of the following happen:
• If you do not stay continuously enrolled in Medicare Part A and Pat�t B.
• If you move out of out� service area.
• If you are away fi•om our service area for more than six months.
• If you move ot• take a long trip, you need to call Metnber Services to find out if
the �lace you are rnoving or traveling to is in our plan's area. (Phone numbers for
Member Services are printed on the back cover of this bookiet.)
If you become incarcerated (go to prison).
If you lie about ot• withhold mforination about other msurance you have that provides
prescription drug coverage.
GRP_12 220 A 160 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 10: Ending your membership in the plan
• �If you intentionally give us incorrect information when you are enrolling in our plan and
that information affects your eligibility for our plan. (We cannot make you leave our plan
for this reason unless we get per�mission fi•om Medicare first.)
• If you continuously behave in a way that is disruptive and makes it difficult fo1� us to
provide medical cat•e for you and other members of our plan. (We cannot make you leave
our plan for this t�eason unless we get permission fi•om Medicar�e first.)
• If you let someone else use your membership card to get medical care or prescription
drugs. (We cannot make you leave our plan for this reason unless we get pet�mission fi•om
Medicare first.)
• If we end your membership because of this reason, Medicare may have your case
investigated by the Inspector General.
• If you do not pay the plan premiums (if applicable) for three months.
� We must notify you in writing that you have tlu�ee months to pay the plan
premium before we end your membership.
• If you have Medicaid and are having difficulty paying your plan premiums or cost
sharing, please contact us.
• If you are requu•ed to pay the extra Part D amount because of your income and you do not
pay it, Medicare will disenroll you fi•om our plan and you will lose prescription drug
coverage.
Where can you get more information?
If you have questions or would like more information on when we can end your membership:
• You can call Member Services for more information (phone numbeis are printed on the
back cover of this booklet).
Section 5.2
We cannot ask you to leave our plan for any reason related to your
health
What should you do if this happens?
If you feel that you are being asked to leave our plan because
should call Medicare at 1-800-MEDICt1RE (1-800-633-4227).
486-2048. You may ca1124 hours a day, 7 days a weelc.
Sectiou 5.3
of a health-related reason, you
TTY users should call 1-877-
You have the right to make a complaint if we end your membership in
our plan
If we end your membership in our plan, we must tell you our reasons in writing for ending your
membeiship. We must also eYplain how you can make a complaint about our decision to end
your membership. You can also look in Chapter 9, Section 10 for information about how to make
a complaint.
GRP 12 220 A 161 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chaptet• 11: Legal notices
Chapter 11. Le�al notices
SECTION 1 Notice about governing law
SECTION 2 Notice about nondiscrimination
SECTION 3 Notice about Medicare Secondary Payer subrogation rights and right of
recovery
SECTION 4 Notice about binding arbitration
SECTION 5 Notice about recovery of overpayments
GRP_12 220 A 162 HMO EOC-with I� (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 1 l: Legal notices
SECTION 1 Notice about governing law
Many laws apply to this Evidence of Coverage and some additional provisions may
because they are required by law. This may affect your rights and responsibilities even
laws are not included or explained in this document. The principal law that applies �
document is Title XVIII of the Social Security Act and the regulations created under the
Security Act by the Centets for Medicare & Medicaid Services, or CMS. In addition,
federal laws may apply and, under certain circumstances, the laws of the state you live in.
SECTION 2 Notice about nondiscrimination
apply
if the
o this
Social
other
We don't discriminate based on a person's race, disability, religion, sex, health, ethnicity, creed,
age, or national origin. All organizations that provide Medicare Advantage Plans, like our plan,
must obey federal laws against discrimination, including Title VI of the Civil Rights Act of
1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with
Disabilities Act, all other laws that apply to organizations that get federal funding, and any other
laws and rules that apply for any other reason.
SECTION 3
Notice about Medicare Secondary Payer subrogation rights
and right of recovery
We have the right and t•esponsibility to collect for covered Medicare services for which Medicare
is not the primary payer. According to CMS regulations at 42 CFR sections 422.108 and
423.462, Aetna Medicare, as a Medicare Advantage Organization, will exercise the same rights
of recovery that the Secretaty exercises under CMS regulations in subparts B through D of part
411 of 42 CFR and the t•ules established in this section supersede any State laws.
In some situations, other parties should pay for your medical care befot•e yout� Medicare
Advantage (MA) health plan. In those situations, your Medicare Advantage plan may pay, but
has the right to get the payments back from these other parties. Medicare Advantage plans may
not be the primaty payer for medical care you receive. These situations include those in which
the Federal Medicare Program is considered a secondary payer under the Medicare Secondary
Payer laws. For information on the Federal Medicare Secondary Payer program, Medicare has
written a booklet with general information about what happens when people with Medicare have
additional insurance. It's called Mediccrre and Othei� Health Benefits: Your� Guide to Who Pcrys
Fzrst (publication number� 02179). You can get a copy by calling 1-800-MEDICARE, 24 hours a
day, 7 days a week, or by visiting the www.medicare.gov web site.
The plan's rights to recover in these situations are based on the terms ofthis health plan contract,
as well as the provisions of the federal statutes governing the Medicare Program. Your MA plan
coverage is always secondary to any payment made or reasonably expected to be made undet :
• A workers' compensation law or plan of the United States ot� a State,
• Any non-fault based insurance, including automobile and non-automobile no-fault and
medical payments insurance,
GRP 12 220 A 163 HMO EOC—with R�c (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 11: Legal notices
• Any liability insul•ance policy or plan (including a self-insuY•ed plan) issued under an
automobile or other type of policy or� coverage, and
• Any automobile insurance policy or plan (including a self-insured plan), including, but
not limited to, uninsured and underinsured motot�ist coverages.
Since your MA plan is always secondary to any automobile no-fault (Personal Injury Protection)
ar• rnedical payments coverage, you should review your automobile insurance policies to ensure
that appropriate policy provisions have been selected to make your automobile coverage primary
for your medical treattnent arising fi•otn an autoinobile accident.
As outlined herein, in these situations, your MA plan may make payments on your behalf for this
medical care, subject to the conditions set forth in this provision for the plan to recover these
payments fi�om you or fi•om other parties. Irnmediately upon making any conditional payment,
your MA plan shall be subt•ogated to (stand in the place o fl all rights of recovery you have
against any person, entity or insurer responsible for causing your injury, illness or condition or
against any person, entity or insurer listed as a prirnaiy payer above.
In addition, if you receive payment from any person, entity or insurer responsible for causing
your injuiy, illness or condition or you receive payment fi•om any peison, entity or insurer listed
as a primary payer above, your MA plan has the right to recover fi•om, and be reimbursed by you
fo�• all conditional payments the plan has made or will make as a�•esult of that injury, illness or
condition.
Your MA plan will automatically have a lien, to the extent of benefits it paid for the treatment of
the injuty, illness or condition, upon any recoveiy whether by settlement, judgment or otherwise.
The lien may be enforced against any party who possesses funds or proceeds representing the
amount of benefits paid by the Plan including, but not lirnited to, you, your representatives or
agents, any person, entity or insul•et• responsible for causing your injuiy, illness or condition or
any person, entity or insurer listed as a primaiy payer above.
By accepting benefits (whether the payment of such benefits is made to you or made on your
behalf to any health cat�e providet•) frotn your MA plan, you acknowledge that the plan's
recovery rights are a iiist priority claim and are to be paid to the plan before any other claim for
your damages. The plan shail be entitled to full reimbursement on a first-dollar basis fi•om any
paynlents, even if such payment to the plan will result in a recoveiy to you which is insufficient
to make you whole or to compensate you in part or in whole for the damages you sustained.
Your MA plan is not required to pat•ticipate in or pay court costs or attorney fees to any attorney
hired by you to putsue your• damage clairns.
Your MA plan is entitled to full recover•y regardless of whetller any liability for payment is
admitted by any person, entity or insurer responsible for causing your injury, illness or condition
or by any person, entity or insur�er listed as a pt•itnary payer above. The plan is entitled to full
recovery regardless of whether the settlement or judgment received by you identifies the medical
bellefits the plan provided or purports to allocate auy poi•tion of such settlement or judgment to
payment of expenses other than medical expenses. The MA plan is entitled to recover from any
GRP_12 220 A 164 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter ll : Legai notices
n,. .
and all settlements or judgments, even those designated as for pain and suffering, non-economic
damages and/or general danlages only.
You, and your legal representatives, shall fully cooperate with the plan's efforts to recover• its
benefits paid. It is your duty to notify the plan within 30 days of the date when notice is given to
any party, including an insurance company or attorney, of your intention to pursue or investigate
a claim to recover damages or obtain compensation due to your injury, illness or condition. You
and your agents or representatives shall provide all information requested by the plan or its
representatives. You shall do nothing to prejudice your MA plan's subrogation or recovery
interest or to prejudice the plan's ability to enforce the terrns of this provision. This includes, but
is not limited to, refraining fi•om making any settlement or t•ecovery that attempts to reduce or
exclude the full cost of all benefits provided by the plan.
Failure to provide requested information or failure to assist your MA plan in pursuit of its
subrogation or recovery rights may result in you being personally responsible for reimbursing the
plan for benefits paid relating to the injuiy, illness or condition as well as for the plan's
reasonable attorney fees and costs incurred in obtaining reimbursement from you. For more
information, see 42 U.S.C. § 1395y(b)(2)(A)(ii) and the Medicare statutes.
SECTION 4 Notice about binding arbitration
Binding arbitration is the final and eYclusive process for resolving any dispute between a
member and the Plan, other than those brought under the Medicare Appeals Procedure. All
interested parties are giving up theu• constitutional right to have thei�• dispute decided in a court
of law before a jury, and instead are accepting the use of binding arbitration.
The agreement to arbitrate includes bad faith claims and disputes that relate to professional
liability or medicai malpractice.
This Evidence of Covef•age also limits certain remedies such as:
• No jury trial: In any dispute ar•ising from or related to coverage, there shall be no right to
a jury triaL This right to trial is waived.
• Medical malpractice claims: Any claim alleging wrongful acts or omissions of
participating providers will not include the Aetna Medicare plan and will only include the
participating provider subject to this allegation. Members waive their f•ight to bi-ing any
claim against Aetna as a party to this claim.
• Class actions: Members cannot participate in a representative capacity as a member of
any class actions relating to plan coverage. Claims brought by membet�s Inay not be
joined ot� consolidated with claims brought by another membet•, unless agreed to in
wt�iting by Aetna.
Unless otherwise agreed by the parties to the arbitration, all disputes shall be submitted to neutral
arbitration within the Aetna Service Area to the American Arbitration Association (AAA) or
such other neutral dispute resolution organization as mutually agreed by the parties. The AAA
GRP 12 220 A 165 HMO EOGwith RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 11: Legal notices
� r. . a .
can be reached by calling 1-800-778-7879. For addftional information on the arbitration process,
contact Member Services at the telephone number on yout• ID card.
SECTION 5 Notice about recovery of overpayments
If the benefits paid by this Evidence of Coverage, plus the benefits paid by other plans, exceeds
the total amount of expenses, Aetna has the right to recover the amount of that excess payment
fi•om among one or more of the following: (1) any pei•son to or for whom such payments were
made; (2) other Plans; or (3) any other entity to which such payments were made. This right of
recovery will be exercised at Aetna's discretion. You shall execute any documents and cooperate
with Aetna to secure its right to recover such overpayments, upon request by Aetna.
GRP_12 220 A 166 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chaptel• 12: Definitions of important words
Chapter 12. Definitions of important words
Ambulatory Surgical Center — An ambulatory surgical center is an entity that operates
exclusively for the purpose of furnishing outpatient surgical services to patients not requiring
hospitalization and whose expected stay in the center does not exceed 24 hours.
Annual Enrollment Period — A set time each fall when all Medicare members can change their
health or drug plans or switch to Original Medicare. The general Medicare Annual Eru•ollment
Period is from October 15 until December 7.
Appeal — An appeal is something you do if you disagree with our decision to deny a request for
coverage of health care services or payment for services you already received. You may also
make an appeal if you disagree with our decision to stop services that you are receiving. For
example, you may ask for an appeal if we don't pay for a drug, item, or service you think you
should be abie to receive. Chapter 9 explains appeals, including the process involved in making
an appeal.
Balance Billing — A situation in which a provider (such as a doctor or hospital) bills a patient
mor�e than the plan's cost-sharing amount for setvices. As a member of our plan, you only have
to pay the plan's cost-sharing amounts when you get services covered by our plan. We do not
allow providers to "balance bill" you. See Chapter 4, Section 1.4 for more information about
balance billing.
Benefit Period —The way that both our plan and Original Medicare measures your use of skilled
nursing facility (SNF) setvices. A benefit period begins the day you go into a skilled nursing
facility. The benefit period ends when you haven't t•eceived any skilled care in a SNF) for 60
days in a row. If you go into a skilled nursing facility a$er one benefit period has ended, a new
benefit period begins. There is no limit to the number of benefit periods.
Brand Name Drug — A prescription drug that is manufactured and sold by the pharmaceutical
company that originally researched and developed the drug. Bt�and name drugs have the same
active-ingredient formula as the generic version of the drug. However, generic drugs are
manufactured and sold by other drug manufacturers and are generally not available until after the
patent on the brand name drug has expired.
Catastrophic Coverage Stage — The stage in the Part D Drug Benefit where you pay a low
copayment or coinsurance for your drugs after you or other qualified parties on your behalf have
spent $4,75o in covered drugs during the covered year.
Centers for Medicare & Medicaid Services (CMS) — The federal agency that administet•s
Medicare. Chapter 2 explains how to contact CMS.
Coinsurance — An amount you may be requit�ed to pay as your share of the cost for services or
prescription drugs after you pay any deductibles. Coinsurance is usually a percentage (for
exarnple, 20%).
GRP 12 220 A 167 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 12: Definitions of important wor•ds
Comprehensive Outpatient Rehabilitation Facilit� (CORF) — A facility that mainly pt�ovides
rehabilitation seivices after an illness or injury, and provides a variety of services including
physical therapy, social or psychological services, respi�•atory thet•apy, occupational therapy and
speech-language pathology setvices, and home environment evaluation setvices.
Copayment — An amount you may be required to pay as your share of the cost for a medical
service or supply, like a doctor's visit, hospital outpatient visit, or a prescription drug. A
copayment is usually a set arnount, rather than a percentage. For example, you might pay $10 or
$20 for a doctor's visit or prescription drug.
Cost Sharing — Cost sharing refets to amounts that a member has to pay when services or drugs
are received (This is in addition to the plan's monthly premium, if applicable.) Cost sharing
includes any coinbination of the following three types of payments: (1) any deductible amount a
plan may impose before services or drugs are covered; (2) any fixed "copayment" amount that a
�lan requires when a specific service or drug is received; or (3) any "coinsurance" amount, a
percentage of the total amount paid for a setvice ot� drug, that a plan requires when a specific
seivice or drug is received.
Cost-Sharing Tier — Every drug on the list of covered drugs is in one of a nurnber of cost-
sharing tiers. In general, the higher the cost-sharing tier, the higher your cost for the drug
Coverage Determination — A decision about whether a drug pt�escribed for you is covered by
the plan and the amount, if any, you are required to pay for the prescription. In general, if you
bring your pr•escription to a pharmacy and the pharmacy tells you the prescription isn't covered
under your plan, that isn't a coverage determination. You need to call or write to yout• plan to ask
for a fot�mal decision about the cover�age. Coverage determinations are called "coverage
decisions" in this booklet. Chapter 9 explains how to ask us for a coverage decision.
Covered Drugs — The term we use to mean all of the pt•escription drugs covered by our plan.
Covered Services — The general ter�m we use in this EOC to mean all of the health care services
and supplies that are covered by our plan.
Creditable Prescription Drug Coverage — Prescription drug coverage (for� exatnple, fiom an
employet� or union) that is expected to pay, on average, at least as much as Medicare's standard
prescription drug coverage. Peopie who have this kind of coverage when they become eligible
for Medicare can generally keep that coverage without paying a penalty, if they decide to ent�oll
in Medicare prescription dr�ug coverage later.
Custodial Care — Custodial care is personal care provided in a nursing home, hospice, or other
facility setting when you do not need skilled medical care or skilled nursing care. Custodial care
is personal care that can be provided by people who don't have pr•ofessional slcills or ti•aining,
such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed
oi• chair, moving az•ound, and using the bathroom. It may also include the kind of health-related
care that most people do themselves, like using eye drops. Medicare doesn't pay for custodial
care.
GRP_12 220 A 168 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chaptei• 12: Definitions of impot•tant words
Deductible — The amount (if applicable) you must pay foz• health care or prescriptions before our
plan begins to pay.
Disenroll or Disenrollment — The process of ending your membership in our plan.
Disem•ollment may be voluntary (your own choice) or involuntaty (not your own choice).
Dispensing Fee — A fee charged each time a covered drug is dispensed to pay for the cost of
filling a prescription. The dispensing fee covers costs such as the pharmacist's time to prepare
and package the prescription.
Durable Medical Equipment — Certain medical equipment that is ordered by yout• doctor for
use at home. Examples are walkers, wheelchairs, or hospital beds.
Emergency — A medical emergency is when you, or any other prudent layperson with an
a�erage knowledge of health and medicine, believe that you have medical symptoms that requu�e
immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb.
The medical symptoms may be an illness, injuzy, severe pain, ot• a medical condition that is
quickly getting worse.
Emergency Care — Covered services that are: 1) rendered by a provider qualified to furnish
emergency services; and 2) needed to evaluate or stabilize an emergency medical condition.
Evidence of Coverage (EOC) and Disclosure Information — This document, along with your
enrollment form and any other attachments, riders, or other optional coverage selected, which
explains your coverage, what we must do, your rights, and what you have to do as a member of
our plan.
Exception — A type of coverage determination that, if approved, allows you to get a drug that is
not on your plan sponsor's formulaly (a formulary exception), or get a non-preferred drug at the
preferred cost-sharing level (a tiering exception). You may also request an exception if your plan
sponsor requires you to try another drug before receiving the drug you are requesting, or the plan
limits the quantity or dosage of the drug you are requesting (a formulary exception).
Extra Help — A Medicare progt•am to help people with limited income and resources pay
Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance.
Generic Drug — A prescription dr�ug that is approved by the Food and Drug Administration
(FDA) as having the same active ingredient(s) as the bt�and name dtug. Generally, a"generic"
drug wot•ks the same as a brand name drug and usually costs less.
Grievance - A type of complaint you make about us or one of our network provideis or
pharmacies, including a complaint concerning the quality of your care. This type of complaint
does not involve coverage oi• payment disputes.
GRP 12 220 A 169 HMO EOC-with I� (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 12: Defmitions of irnpot•tant words
Home Health Aide — A home health aide provides services that don't need the skills of a
licensed nurse or therapist, such as help with personal care (e.g., bathing, using the toilet,
dressing, or carrying out the prescribed exer•cises). Home health aides do not have a nui•sing
license or provide therapy.
Hospital Inpatient Stay — A hospital stay when you have been formally adrnitted to the hospital
for skilled medical services. Even if you stay in the hospital overnight, you might still be
considered an "outpatient."
Initial Coverage Limit — The maximmn liiYlit of coverage under the Initial Coverage Stage.
Initial Coverage Stage — This is the stage before your total drug expenses have t�eached $2,970,
including amounts you've paid and what our plan has paid on your behalf.
Initial Enrollment Period — When you are first eligible for Medicar•e, the period of time when
you can sign up for Medicare Part B. For example, if you're eligible for Part B when you tut•n 65,
your Initial Enrollment Period is the 7-month period that begins 3 months before the month you
turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.
Late Enrollment Penalty — An amount added to your monthly premium for Medicare drug
coverage if you go without creditable coverage (coverage that is expected to pay, on average, at
least as much as standard Medicare prescription drug coverage) for a continuous pet•iod of 63
days or more. You pay this higher amount as long as you have a Medicare drug plan. There are
some exceptions. For example, if you receive Extra Help from Medicare to pay your prescription
drug plan costs, the late enrollment penalty rules do not apply to you. If you receive Extra Help,
you do not pay a penalty, even if you go without "creditable" presct�iption drug coverage.
List of Covered Drugs (Formulary or "Drug LisN') — A list of prescription drugs covered by
the plan. The drugs on this list are selected by the plan with the help of doctors and pharmacists.
The list includes both brand name and genet�ic drugs.
Low Income Subsidy (LIS) — See `Bxtra Help."
Maximum Out-of-Pocket Amount — The most that you pay out-of-pocket during the calendar�
year for in-network covered Part A and Part B setvices. Amounts you pay fot� your plan
premiums and Medicare Pat�t A and Part B premiums do not count toward the maxllllum out-of-
pocket amount. See Chapter 4, Section 1.2 fot• information about your maximum out-of-pocket
amount.
Medicaid (or Medical Assistance) — A joint federal and state prograrn that helps with medical
costs for some people with low incomes and limited resources. Medicaid programs vaty from
state to state, but most health care costs are covered if you qualify for both Medicare and
Medicaid. See Addenduin A for information about how to contact Medicaid in your state.
GRP_12 220 A 170 HMO EOC-witli Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 12: Defmitions of important words
Medically Accepted Indication — A use of a drug that is either approved by the Food and Drug
Administration or supported by certain reference books. See Chapter 5, Section 4 for more
information about a medically accepted indication.
Medically Necessary — Services, supplies, ot� drugs that are needed for the prevention, diagnosis,
or treatment of your medical condition and meet accepted standat•ds of inedical practice.
Medicare — The federal health insurance program for people 65 years of age or older, some
people under age 65 with certain disabilities, and people with End-Stage Renal Disease
(generally those with permanent kidney failure who need dialysis or a kidney transplant). People
with Medicare can get theu� Medicare health coverage through Original Medicare, a Medicare
Cost Plan, (where available) a PACE plan, (where available) or a Medicare Advantage Plan.
Medicare Advantage Disenrollment Period — A set time each year when members in a
Medicat•e Advantage plan can cancel thei� plan enrollment and switch to Original Medicare. The
Medicar�e Advantage Disent•ollment Period is fi�om Januaty 1 until February 14, 2013.
Medicare Advantage (MA) Plan — Sometimes called Medicare Part C. A plan offered by a
private company that contracts with Medicare to provide you with all your Medicare Part A and
Part B benefits. A Medicare Advantage Plan can be an HMO, PPO, a Private Fee-for-Service
(PFFS) plan, or a Medicare Medical Savings Account (MSA) plan. When you are enrolled in a
Medicare Advantage Plan, Medicare seivices are covered through the plan, and are not paid for
under Original Medicare. In most cases, Medicat•e Advantage Plans also offer Medicare Part D
(prescr•iption drug coverage). These plans are called Medicare Advantage Plans with
Prescription Drug Coverage.
Medicare Cost Plan — A Medicare Cost Plan is a plan operated by a Health Maintenance
Organization (HMO) or Competitive Medical Plan (CMP) in accordance with a cost-reimbutsed
contract under section 1876(h) of the Act.
Medicare Coverage Gap Discount Program — A program that provides discounts on most
covet�ed Pat•t D brand name dt•ugs to Part D enrollees who have reached the Coverage Gap Stage
and who are not al�eady receiving "Extra Help." Discounts at•e based on agreements between the
federal government and certain drug manufacturers. For this reason, most, but not all, brand
name di-ugs are discounted.
Medicare-Covered Services — Services covered by Medicare Part A and Part B. All Medicare
health plans, including our plan, must cover all of the services that are covered by Medicare Pat�t
A and B.
Medicare Health Plan — A Medicare health plan is offered by a private company that contracts
with Medicare to provide Part A and Pat-t B benefits to people with Medicare who enroll in the
plan. This term includes all Medicare Advantage Plans, Medicare Cost Plans,
Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE).
GRP 12 220 A 171 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage fot• Aetna MedicareSM Plan (I�VIO)
Chapter 12: Defmitions of impor•tant words
Medicare Prescription Drug Coverage (Medicare Part D) — Insurance to help pay for
outpatient prescri�tion drugs, vaccines, biologicals, and some supplies not covered by Medicare
Pat•t A or Part B.
"Medigap" (Medicare Supplement Insurance) Policy — Medicat•e supplement insurance sold
by private insurance companies to fill "gaps" in Original Medicare. Medigap policies only work
with Original Medicare. (A Medicare Advantage Plan is not a Medigap policy.)
Member (Member of our Plan, or "Plan Member") — A person with Medicare who is eligible
to get covered services, who has enrolled in our plan and whose enrollment has been confirmed
by the Centers for Medicare & Medicaid Services (CMS).
Member Services — A department within our plan responsible for answering your questions
about your membership, benefits, grievances, and appeals. See Chapter 2 for information about
how to contact Member Services.
Network — A group of doctors, hospitals, pharmacies, and other health care experts contracted
by Aetna to provide covered setvices to its members (see Chapter 1, Section 3.2). Network
providers are independent contractors and not agents of Aetna.
Network Pharmacy — A network pharmacy is a pharmacy where members of our plan can get
then� prescription drug benefits. We call them "network pharmacies" because they contract with
our plan. In tnost cases, your prescriptions are covered only if they are filled at one of our
network pharmacies.
Network Provider —"Providet•" is the genet•al term we use for doctors, other health care
professionals, hospitals, and othet� health care facilities that are licensed or certified by Medicare
and by the state to provide health care services. We call them "network providers" when they
have an agreement with our plan to accept our payment as payment in full, and in some cases to
coordinate as well as provide covered setvices to membeis of our plan. Our� plan pays network
providers based on the agreements it has with the providers or if the pt•oviders agree to provide
you with plan-covered services. Networlc �roviders may also be referred to as "plan providers."
Organization Determination - The Medicare Advantage ot•ganization has made an organization
determination when it makes a decision about whether services are covered or how much you
ha�e to pay for covered items or services. The Medicare Advantage organization's networ�k
provider or facility has also made an organization deterrnination when it provides you with an
item or service, or refers you to an out-of-networlc provider for an item or� se�•vice. Organization
determinations are called "coverage decisions" in this boolclet. Chapter 9 explains how to ask us
for a coverage decision.
Original Medicare ("Traditional Medicare" or� "Fee-for-service" Medicare) — Original Medicare
is offet•ed by the gover�nment, and not a private heaith plan such as Medicat�e Advantage Plans
and prescription drug plans. Under Original Medicare, Medicare services are covered by paying
doctors, hospitals, and other health care providet�s payment amounts established by Congress.
You can see any doctor, hospital, or other health care provider that accepts Medicare. You rnust
GRP_12 220 A 172 HMO EOC-with RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 12: Defmitions of important words
pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your
share. Original Medicare has two parts: Part A(Hospital Insurance) and Part B(Medical
Insurance) and is available everywhere in the United States.
Out-of-Network Pharmacy — A pharmacy that doesn't have a contract with our plan to
coordinate or provide covered drugs to members of our plan. As explained in this Evidence of
Coverage, most drugs you get fi•om out-of-network pharmacies are not covered by our plan
unless certain conditions apply.
Out-of-Network Provider or Out-of-Network Facility — A provider or facility with which we
have not arranged to coordinate or provide covered setvices to members of our plan. Out-of-
network providers are providers that are not employed, owned, or operated by our plan or are not
under contract to deliver covered services to you. Using out-of-network providers or facilities is
explained in this booklet in Chapter 3.
Out-of-Pocket Costs — See the defmition for "cost sharing" above. A member's cost-sharing
requirement to pay for a portion of services or drugs received is also referred to as the member's
"out-of-pocket" cost requirement.
PACE plan — A PACE (Program of All-Inclusive Care for the Elderly) plan combines medical,
social, and long-term care services for frail people to help people stay independent and living in
their community (instead of moving to a nursing home) as long as possible, while getting the
high-quality care they need. People enrolled in PACE plans receive both theu• Medicare and
Medicaid benefits through the plan.
Part C— see "Medicare Advantage (MA) Plan."
Part D— The voluntaiy Medicare Prescription Drug Benefit Program. (For ease of reference, we
will t•efer to the prescription drug benefit program as Part D.)
Part D Drugs — Di•ugs that can be covered under Part D. We may or may not offer all Part D
drugs. (See your formulary for a specific list of covered drugs.) Certain categories of drugs were
specifically excluded by Congress �•om being covered as Part D dt�ugs.
Preferred Provider Organization (PPO) Plan — A Prefet•red Provider Organization plan is a
Medicare Advantage Plan that has a network of contracted providers that have agreed to treat
plan members for a specified payment amount. A PPO plan must cover all plan benefits whether
they are received from network or out-of-network providers. Member cost sharing will generally
be higher when plan benefits are received fi�om out-of-network providers. PPO plans ha�e an
annual limit on your out-of-pocket costs for services received from network (preferred) provideis
and a higher limit on your total combined out-of-pocket costs for services from both in-network
(preferred) and out-of-network (non-preferred) providers.
Premium — The periodic payment to Medicare, an insurance company, or a health care plan for
health or prescription drug coverage.
GRP 12 220 A 173 HMO EOC-with I� (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 12: Definitions of important words
Primary Care Physician (PCP) — Your primaty care physician is the doctor or other provider
you see first for most health pt•oblems. He or she makes sure you get the care you need to keep
you healthy. He or she also may talk with other doctois and health care providers about your care
and refer you to them. In tnany Medicare health plans, you must see your pr�imaiy care providet•
before you see any other health care provider. See Chapter 3, Section 2.1 for information about
primary care physicians.
Prior Authorization — Approval in advance to get services or certain drugs that may or may not
be on our formulary. Some in-network medical services are covered only if your doctor� or other
network provider gets "prior authorization" from our plan. Covered services that need prior
authorization are marked in the Benefits Chart included with this Evidence of Coverage. Some
drugs are covered only if your doctor or other network provider gets "prior authorization" from
us. Covered drugs that need prior authorization are marked in the formulary.
Quality Improvement Organization (QIO) — A group of practicing doctot�s and other health
cat�e experts paid by the federal government to check and improve the care given to Medicare
patients. See Addendum A for� infol�mation about how to contact the QIO for your state.
Quantity Limits — A inanagement tool that is designed to limit the use of selected drugs for
quality, safety, ot� utilization reasons. Limits may be on the amount ofthe drug that we cover per
prescription or for a defined period of time.
Rehabilitation Services — These setvices include physical therapy, speech and language
therapy, and occupational therapy.
Service Area — A geographic area where a health plan accepts membets if it limits membership
based on where people live. For plans that limit which doctois and hospitals you may use, it's
also generally the area where you can get routine (non-emergency) services. The plan may
disenroll you if you move out of the plan's service area.
Skilled Nursing Facility (SNF) Care — Skilled nursing care and rehabilitation services provided
on a cotitinuous, daily basis, in a skilled nursing facility. Examples of skilled nursing facility care
include physical thei•apy or iutravenous injections that can only be given by a registered nurse or
doctor.
Special Enrollment Period — A set time when inembets can change their health or drug plans or
returii to Ol•iginal Medicare. Situations iu which you may be eligible for a Special Enrollment
Per�iod include: if you move outside the service area, if you at•e getting "Ea�tra Help" with your
prescription drug costs, if you move into a nutsing home, if we violate our contract with you, ot�
if you are a member of our plan through an em�loyer/union/ t�-ust group retit�ee plan.
Special Needs Plan — A special type of Medicare Advantage Plan that provides tnore focused
health care for� specific groups of people, such as those who have both Medicare and Medicaid,
who reside in a nu�sing home, or who have certain chronic medical conditions.
GRP_12 220 A 174 HMO EOGwith RY (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Chapter 12: Definitions of important words
Step Therapy — A utilization tool that requires you to first try another drug to tt•eat your medical
condition before we will cover the drug your physician may have initially prescribed.
Supplemental Security Income (SSI) — A monthly benefit paid by Social Security to people
with limited income and resources who are disabled, blind, or age 65 and older. SSI benefits are
not the same as Social Secur�ity benefits.
Urgently Needed Care — Urgently needed care is care provided to treat a non-emergency,
unforeseen medical illness, injury, or condition, that requi��es immediate medical care. Urgently
needed care may be furnished by network providers or by out-of-network providets when
network providers are temporarily unavailable or inaccessible.
GRP 12 220 A 175 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna Medicat�eSM Plan (HMO)
Addendum A
ADDENDUM A
AETNA MEDICARESM PLAN (HMO)
2013 EVIDENCE OF COVERAGE
lm ortant Contact Information for State A encies
Arizona
Quality Improvement Health Services Advisory Group, Inc.
Organization 3133 East Camelback Road, Suite 300
Phoenix, AZ 85016-4501
Phone: 602-264-6382 / 800-359-9909
www.hsag.com
State Health Insurance Arizona State Health Insurance Assistance Progt•am
Assistance Progi�am DES Division of Aging and Adult Seivices
1789 W. Jefferson St. (Site Code 950A)
Phoenix, AZ 85007
Phone: 602-542-4446 / 800-432-4040
www. azdes. gov/aaa/programs/ship
State Medical Assistance Health Care Cost Containment of Arizona
Office 801 E. Jefferson Street, MD 4100
Phoenix, AZ 85034
Phone: 602-417-7000 / 800-654-8713
http://www.ahcccs. state. az.us
California
Quality Improvement Health Services Advisoiy Group
Organization 700 North Brand Boulevard, Suite 300
Glendale, CA 91203
Phone: 866-800-8749
TTY: 800-881-5980
www.hsag.com
State Health Insurance California Health Insurance Counseling & Advocacy Program
Assistance Program (HICAP)
Departtnent of Aging
1300 National Drive
Sacramento, CA 95834
Phone: 800-434-0222
www.aging.ca.gov/HICAP
State Medical Assistance Califor•nia Depat�tment of Health Setvices
Office 1501 Capitol Avenue, MS 4604
Sacramento, CA 95814
Phone: 916-636-1980 I 800-541-5555
TTY: 800-735-2929
www.medi-cal.ca.gov
Colorado
Quality Improvement Colorado Foundation fot� Medical Care
Organization 23 Invet•ness Way East, Suite 100
Engiewood, CO 80112-5708
GRP_12 220 A 176 HMO EOC—with Rac (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Addendum A
Phone: 303-695-3300 / 800-727-7086
www.cfmc.org
State Health Insurance Senior Health Insurance Assistance Program (SHIP)
Assistance Program 1560 Broadway, Suite 850
Denver, CO 80202
Phone: 303-894-7499 / 800-930-3745
TTY: 303-894-7880
www.dora.state. co.us/insurance/senior/senior.htm
State Medical Assistance Department of Health Care Policy and Financing of Colorado
Office 1570 Grant Street
Denver, CO 80203-1818
Phone: 303-866-2993 / 800-221-3943
http://www.chcpf. state.co.us
State Pharmaceutical Colorado Bridging the Gap - Colorado Department of Public
Assistance Program Health and Environment
4300 Cherry Creek Drive South
DCEED-STD-A3
Denver, CO 80246-1530
Phone: 303-692-2700
TTY: 303-691-7719
http:/lwww.cdphe.state.co.us/dc/I Il VandSTD/ryanwhite/medicared.htm
1
Connecticut
Quality Improvement Qualidigm
Organization 1111 Cromwell Avenue, Suite 201
Rocky Hill, CT 06067-3454
Phone: 860-632-2008 / 800-553-7590
www.qualidigm.org
State Health Insurance CHOICES
Assistance Pr�ogt•am Department of Social Services, Aging Services Division
25 Sigourney Street, l Oth Floor
Hartford, CT 06106
Phone: 860-424-5274 I 866-218-6631
www. ct. gov/agingservices
State Medical Assistance Department of Social Setvices of Connecticut
Office 25 Sigourney Street
Hartford, CT 06106-5033
Phone: 860-424-4908 / 800-842-1508
http://www.dss. state. ct.us
State Pharmaceutical ConnPACE - Connecticut Department of Social Services
Assistance Program P.O. Box 5011
Hartford, CT 06102
Phone: 860-269-2029/800-423-5026
http://www.connpace.com/
Delaware
Quality Impt•ovement Quality Insights of Delaware
GRP 12 220 A 177 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Addendum A
Organization Baynard Bldg. Suite 100
3411 Silverside Road
Wilmington, DE 19810-4812
Phone: 302-478-3600 / 866-475-9669
http://www.wvini.org/corp/
State Health Insurance ELDERinfo
Assistance Program 841 Silver Lake Blvd
Dover, DE 19904
Phone: 302-674-7364 / 800-336-9500
http://delawareinsurance. gov/departments/elder/eldindex. shtml
State Medical Assistance Delaware Health and Social Services
Office 1901 N. Du Pont Highway, Lewis Bldg.
New Castle, DE 19720
Phone: 302-255-9500 / 800-372-2022
www. state.de.us/dhss
State Pharmaceutical Chronic Renal Disease Program
Assistance Program 11-13 Church Ave.
Milford, DE 19963
Phone: 302-424-7180 / 800-464-4357
http:/Iwww. dhss.delaware. gov/dhss/dmma/crdprog.html
District of Columbia
Quality Impt�ovement Delmarva Foundation for Medical Care, Inc.
Organization 9240 Centreville Road
Easton, MD 21601
Phone: 202-293-9650 / 800-937-3362
www. de lmarvafoundati on. org
State Health Insut�ance Health Insttt•ance Counseling Project (HICP)
Assistance Program 441 4th Street, NW Suite 900 South
Washington, DC 20001
Phone: 202-739-0668
TTY: 202-724-8925
http:Udcoa. dc.gov/dcoa.site/default.asp
State Medical Assistance DC Healthy Family
Office 899 North Capitol Street, NE
Washington, DC 20002
Phone: 202-724-5506 / 888-557-1116
www.doh.dc.gov
Florida
Quality Improvement Flot�ida Medical Quality Assut�ance
Organization 5201 W. Kennedy Boulevard Suite 900
Tampa, FL 33609-1822
Phone: 813-354-9111 / 800-844-0795
www.finqai.com
State Health Insut•ance Serving Health Insurance Needs of Elders (SHINE)
Assistance Pr�ogram Depat�tment of Elder Affau•s
4040 Esplanade Way
GRP_12 220 A 178 HMO EOC-with I� (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Addendum A
Tallahassee, FL 32399-7000
Phone: 850-414-2000/800-963-5337
TTY: 800-414-2001
http:Uwww.FloridaShine. org
State Medical Assistance Agency for Health Care Administration of Florida
Office 2727 Mahan Drive
Tallahassee, FL 32308
Phone: 850-487-1111 / 866-762-2237
www. fdhc. state. fl. us/
Geor ia
Quality Improvement Georgia Medical Care Foundation
Organization 1455 Lincoln Parkway, Suite 800
Atlanta, GA 30346
Phone: 404-982-0411 / 800-982-04ll
www.gmcf.org
State Health Insurance GeorgiaCares
Assistance Program 2 Peachtree Street, NW
Atlanta, GA 30303
404-657-5258 / 800-669-8387
Phone: TTY: 404-657-1929
www. dhr.geot•gia.gov
State Medical Assistance Georgia Department of Community Health
Office 2 Peachtree Street, NW
Atlanta, GA 30303
Phone: 404-651-9982 / 800-869-ll50
www.dch.georgia.gov
Tllinois
Quality Improvement Illinois Foundation for Quality Health Care
Organization 711 Jorie Blvd., Suite #301
Oak Brook, IL 60523-4425
Phone: 630-928-5800 / 800-647-8089
www.ifmc-il.org
State Health Insut•ance Senior Health Insurance Program (SHIP)
Assistance Pr�ogram 320 West Washington St.
Springfield, IL 62767-0001
Phone: 217-785-9021 / 800-548-9034
TTY: 217-524-4872
http://insurance. illino is.gov/SHIP/
State Medical Assistance Illinois Department ofHealthcare and Family Seivices
Office 201 South Grand Avenue East
Springfield, IL 62763-0001
Phone: 217-782-1200 / 800-226-0768
TTY: 800-526-5812
http://www.hfs. i llino is. gov/
State Pharmaceutical Illinois Cares Rx Plus - Illinois Department on Aging
Assistance Program P.O. Box 19003
GRP_12 220 A 179 HMO EOC-with 1� (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Addendum A
Springfield, IL 62794
Phone: 800-624-2459
TTY: 800-206-1327
http://www. illino iscarestx.com/
Indiana
Quality Impr•ovement Health Care Excel, Inc.
Organization 2629 Waterfront Parkway East Drive, Suite 150
Indianapolis, IN 46214
Phone: 317-347-4500 / 800-288-1499
www.hce.org
State Health Insur�ance State Health Insurance Assistance Program (SHIP)
Assistance Program 714 West 53rd Street
Anderson, IN 46013
Phone: 765-608-2318 / 500-452-4800
TTY: 866-846-0139
www.medicare.in.gov
State Medical Assistance Family and Social Seivices Administration of Indiana
Office P.O. Box 7083
402 W. Washington St�•eet
Indianapolis, IN 46207-7083
Phone: 317-233-4454 / 800-403-0864
htt ://www.in.gov/fssa/
State Pharmaceutical Hoosierl�
Assistance Progr�am P.O. Box 6224
Indianapolis, IN 46206
Phone: 317-234-1381 / 866-267-4679
http://www. in.gov/fssa/elderly/hoosiertx/
Kansas
Quality Improvement Kansas Foundation for Medical Care
Organization 2947 SW Wanamaker Drive
Topeka, KS 66614-4193
Phone: 785-273-2552 / 800-432-0770
www.kfmc.org
State Health Insurance Senior Health Insurance Counseling for Kansas (SHICK)
Assistance Program 503 S. Kansas Avenue
Topeka, KS 66603
Phone: 316-337-7386 / 800-432-3535
www.agingkansas.org
State Medical Assistance Department of Social and Rehabilitation Services of Kansas
Office 915 Southwest Hart•ison Street
Topeka, KS 66612
Phone: 785-296-3981 / 800-766-9012
TTY: 785-296-1491
http : Uwww. stskansas. org/hcp/
Kentucl
Quality Improvement Health Care Excel, Inc.
GRP 12 220 A 180 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Addendum A
Organization 2629 Waterfi•ont Parkway East Drive, Suite 150
Indianapolis, IN 46214
Phone: 317-347-4500 / 800-288-1499
www.hce.org
State Health Insurance State Health Insurance Assistance Program (SHIP)
Assistance Program 275 E. Main St., 3E-E
Frankfort, KY 40621
Phone: 502-564-6930 / 877-293-7447
TTY: 888-642-1137
http://www.chfs. ky.gov/dail/ship.htm
State Medical Assistance Cabinet for Health Services of Kentucky
Office 275 E. Main St.
Frankfort, KY 40621
Phone: 502-564-4321 / 800-635-2570
www.chfs.ky.gov
Maine
Quality Improvement Northeast Health Car�e Quality Foundation
Organization 15 Old Rollinsford Rd., Suite 302
Dover, NH 03820
Phone: 603-749-1641 ! 800-772-0151
TTY: 877-486-2048
www.nhcqf.org
State Health Insurance Maine State Health Insurance Assistance Program (SHIP)
Assistance Program 11 State House Station, 32 Blossom Lane
Augusta, ME 04333
Phone: 207-287-9200 / 800-262-2232
TTY: 800-606-0215
http://www.maine.gov/dhhs/oes/hiap/index. shtml
State Medical Assistance Maine Depat�tment of Health and Human Seivices
Office 11 State House Station
Augusta, ME 04333-0011
Phone: 207-287-9202 / 800-977-6740
TTY: 800-606-0215
www.maine.gov/dhhs/bms
State Pharmaceutical Maine Low Cost Drugs for the Elderly or Disabled Program -
Assistance Program Office of MaineCare Services
442 Civic Center Drive
Augusta, ME 04333
Phone: 888-600-2466 / 866-796-2463
TTY: 800-606-0215
http://www.maine.gov/dhhs/beas/resource/lc drugs.htm
Ma land ' —
Quality Improvement Delmarva Foundation for Medical Care, Inc.
Organization 9240 Centreville Road
Easton, NID 21601
Phone: 410-822-0697 / 800-999-3362
GRP 12 220 A 181 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Addendum A
wtivw. de Im arvafo und ation. org
State Health Insurance Senior Health Insurance Assistance Program (SHIP)
Assistance Program 301 West Preston Street, Suite 1007
Baltimore, NID 21201
Phone: 410-767-1100 / 800-243-3425
TTY: 800-201-7165
http://www.mdoa. state.md.us
State Medical Assistance Departtnent of Health and Mental Hygiene
O�ce 201 West Preston Street
Baltimore, MD 21201
Phone: 410-767-5800 / 800-492-5231
www. dlunh. state. tnd. us
State Pharmaceutical Maryland Senior Prescr•iption Drug Assistance Program - c/o
Assistance Pt•ogram Pool Administrator•s
628 Hebron Avenue, Suite 212
Glastonbuiy, CT 06033
Phone: 800-551-5995
TTY: 800-877-5156
http:Umarylandspdap. com
Massachusetts
Quality Iinpr•overnent MassPRO
Organization 245 Winter St.
Waltham, MA 02451-1231
Phone: 781-890-0011 / 800-252-5533
www.masspro.org
State Health Insurance Serving Health Information Needs of Eldets (SHINE)
Assistance Program One Ashburton Place, Sth Floor
Boston, MA 02108
Phone: 617-727-7750 / 800-243-4636
www.800ageinfo.cotn
State Medical Assistance Office of Health and Human Setvices of Massachusetts
Office One Ashburton Place, l lth Floot•
Boston, MA 02108
Phone: 617-573-1600 / 800-841-2900
www.mass. gov/tnasshealth
State Pharrnaceutical Massachusetts Prescription Advantage
Assistance Program P.O. Box 15153
Worcester, MA 01615
Phone: 800-2�3-4636
TTY: 877-610-0241
http://www.mass.gov/?pageID=eldersterm inal&L=3 &LO=Home
&L 1=Health+Care&L2=Prescription+Advantage&sid=Eelders&
b=terminalcontent&�pa_overview&csid=Eelders
Michigan
Quality Irnprovement Michigan Peer Review Organization
Otganization 22670 Haggerty Road, Suite 100
GRP_12 220 A 182 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Addendum A
Farmington Hills, MI 48335-26ll
Phone: 248-465-7300 / 800-365-5899
www.mpro.org
State Health Insurance MMAP, Inc.
Assistance Program 6105 West St. Joseph, Suite 204
Lansing, MI 48917-4850
Phone: 800-803-7174
mmapinc.org
State Medical Assistance Michigan Department Community Health
Office 201 Townsend Street
Lansing, MI 48913
Phone: 517-373-3740 / 800-642-3195
TTY: 800-649-3777
www.michigan.gov/mdch
Mississi pi
Quality Improvement Information and Quality Healthcat•e
Organization 385B Highland Colony Parkway, Suite 504
Ridgeland, MS 39157
Phone: 601-957-1575 / 800-844-0600
www.iqh.org
State Health Insurance MS State Health Insurance Assistance Program (SHIP)
Assistance Program 750 North State Street
Jackson, MS 39202
Phone: 601-359-4929 / 800-948-3090
http://www.mdhs. state.ms.us/aas_ship.html
State Medical Assistance Offce of the Governor of Mississippi
Office 550 High Street, Suite 1000
Jackson, MS 39201-1399
Phone: 601-359-6050 / 800-421-2408
medicaid.ms.gov/
Missouri
Quality Improvement Pritnaris
Organization 200 N. Keene Street, Ste. 101
Columbia, MO 65201
Phone: 573-817-8300 / 800-735-6776
http:/Iwww.primaris.org/
State Health Insurance CLAIM
Assistance Program 200 N. Keene St.
Columbia, MO 65201
Phone: 573-817-8320 / 800-390-3330
www.missouriclaim.org
State Medical Assistance Department of Social Seivices of Missouri - MO HealthNet
Office Division
615 Howerton Court, P.O. Box 6500
Jefferson City, MO 65102-6500
Phone: 573-751-3425 / 800-392-2161
GRP 12 220 A 183 HMO EOC—with Rac (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Addendum A
TTY: 800-735-2966
www. ds s.tn o. gov/mhd/
State Pharrnaceutical Missouri RY Plan
Assistance Pi•ogram P.O. Box 6500
Jefferson City, MO 65102
Phone: 573-751-3425 / 800-375-1406
TTY: 800-735-2966
http://motx.mo.gov/
Nevada
Quality Improvement HealtliInsight
Organization 6830 W. Oquendo Road, Suite 102
Las Vegas, NV 89118
Phone: 702-385-9933 / 800-748-6773
www.healthinsight.org
State Health Insurance State Health Insurance Assistance Program (SHIP)
Assistance Program 3416 Goni Road, Suite D-132
Carson City, NV 89706
Phone: 702-486-3478 / 800-307-4444
www.nvaging.net
State Medical Assistance Nevada Department of Human Resources, Aging Division
Office 1100 E. Wiiliam Street, Suite 101
Carson City, NV 89701
Phone: 775-684-3600 / 800-992-0900
TTY: 775-684-0760
http://dhcfp. state.nv.us/
State Pharmaceutical Nevada Disability RY-Department of Health and Human
Assistance Program Services
3416 Goni Road, Suite D-113
Carson City, NV 89706
Phone: 775-687-4210 / 866-303-6323
http:l/dhhs.nv.gov/Disability�.htm
New Jersey
Quality Improvement Health Care Quality Strategies
Organization 557 Cranbuly Road, Suite 21
East Brunswick, NJ 08816
Phone: 732-238-5570/800-624-4557
TTY: 877-486-8048
www.hqsi.org
State Health Insut•ance State Health Insurance Assistance Prograin (SHIP)
Assistance Program P. O. Box 360
Trenton, NJ 08625-0360
Phone: 877-222-3737 / 800-792-8820
www. state.nj .us/health/senior/sh ip. shttnl
State Medical Assistance Department of Human Services of New Jetsey
Office P.O. Box 712
GRP_12 220 A 184 HMO EOC-with Rx (Y2013)
2013 Evidence of Covet�age for Aetna MedicareSM Plan (HMO)
Addendum A
Trenton, NJ 08625-0712
Phone: 800-356-1561
www. state.nj .us/hurnanservices/dmahs
State Pharmaceutical New Jetsey Division of Medical Assistance and Health Seivices
Assistance Program Quakerbridge Plaza, P.O. Box 712
Trenton, NJ 08625
Phone: 800-356-1561
http://www.state.nj .us/humanservices/dmahs/index.html
New Mexico
Quality Improvement New Mexico Medical Review Association
Organization 5801 Osuna Road NE, Suite 200
Albuquerque, NM 87109
Phone: 505-998-9898 / 800-663-6351
www.nmmra.org
State Health Insurance Benefits Counseling Program
Assistance Program 2550 Cerrillos Road
Santa Fe, NM 87505
Phone: 505-476-4846 / 800-432-2080
TTY: 800-659-8331
www.nmaging. state.nm.us
State Medical Assistance Department of Human Services of New Mexico
Office P.O. Box 2348
Santa Fe, NM 87504-2348
Phone: 505-827-3100 / 888-997-2583
http:Uwww. state.nm.us/hsd/mad/Index.html
New York
Quality Improvement Island Peer Review Organization - IPRO
Organization 1979 Marcus Avenue
Lake Success, NY 11042-1002
Phone: 516-326-7767 / 800-331-7767
TTY: 516-326-6182
www.ipro.org
State Health Insurance Health Insui•ance Information Counseling and Assistance
Assistance Program Program (HIICAP)
162 Washington Ave.
Albany, NY 12210
Phone: 800-342-9871 / 800-701-0501
TTY: 877-486-2048
www.aging.ny.gov/
State Medical Assistance New Yot�k State Depat-tment of Health
Office P.O. Box 2798
New York, NY 1 0 1 1 7-2273
Phone: 518-486-9057 / 800-541-2831
http://www.health. state.ny. us!
State Pharmaceutical New York State Elderly Pharmaceutical Insurance Coverage
GRP 12 220 A 185 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Addendum A
Assistance Program (EPIC�
P.O. Box 15018
Albany, NY 12212
Phone: 800-332-3742
http://www.health. state.ny. us/nysdoh/epic/faq.htm
North Carolina
Quality Improvement Medical Review of North Carolina, Inc.
Organization 100 Regency Forest Drive, Suite 200
Cary, NC 27515-8598
Phone: 919-380-9860 / 800-682-2650
www.thecarolinascenter. org/
State Health Insurance Seniors' Health Insurance Infoi�mation Program (SHIIP)
Assistance Program 11 South Boylan Avenue
Raleigh, NC 27603
Phone: 919-807-6900 / 800-443-9354
TTY: 919-715-0319
http://www. ncdoi. co m/SHIIP/shiip_contact. asp
State Medical Assistance North Carolina Department of Health and Human Seivices
Office 2001 Mail Service Center
Raleigh, NC 27699-2001
Phone: 919-855-4400/800-662-7030
TTY: 919-733-4851
www. dhhs. state. nc.us/dma/mqb. html
State Pharmaceutical North Carolina HIV SPAP
Assistance Program 1902 Mail Setvice Center
Raleigh, NC 27699
Phone: 919-733-7301 / 877-466-2232
http://www. epi, state.nc.us/epi/hiv/adap.htm 1
Ohio
Quality Improvement Ohio KePRO, Inc.
Organization Rock Run Center, Suite 100
5700 Lombardo Center Dr.
Seven Hills, OH 44131
Phone: 216-447-9604 / 800-589-7337
www.ohiokepro.com
State Health Insurance Ohio Senior Health Insurance Infornlation Program (OSHIIP)
Assistance Program 50 W. Town Street, Third Floor - Suite 300
Coluinbus, OH 43215
Phone: 614-644-3458 / 800-686-1578
TTY: 614-644-3745
www. insurance. oh io. gov
State Medical Assistance Department of Job and Family Services of Ohio - Ohio Health
Office Plans
50 West Town Street
Columbus, OH 43215
Phone: 614-644-0140 / 800-324-8680
GRP_12 220 A 186 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Addendum A
http://j fs. ohio.gov/ohp
Okiahoma
Quality Improvement Oklahoma Foundation for Medical Quality, Inc.
Organization 14000 Quail Springs Parkway, Suite 400
Oklahoma City, OK 73134-2600
Phone: 405-840-1343/800-522-3414
www.ofmq.com
State Health Insurance Senior Health Insurance Counseling Program (SHIP)
Assistance Program 4157 S. Harvard, Suite. 121
Tulsa, OK 74135
Phone: 405-521-6628/800-763-2828
www.oid.state.ok.us
State Medical Assistance Health Care Authority of Oklahoma
Office 2401 N.W. 23rd St., Suite lA
Oklahoma City, OK 73107
Phone: 405-522-7171 / 800-522-0310
www.okhca.org
Penns ivania
Quality Impi•ovement Quality Insights of Pennsylvania
Organization 2601 Market Place Street, Suite 320
Harrisburg, PA 17110
Phone: 717-671-5425 / 877-346-6180
www.qipa.org
State Health Insurance APPRISE
Assistance Program 555 Walnut Street, Sth Floor
Harrisburg, PA 17101-1919
Phone: 717-783-1550 / 800-783-7067
www.aging.state.pa.us
State Medical Assistance Department of Public Welfare of Pennsylvania
Office P.O. Box 2675
Harrisburg, PA 17105-2675
Phone: 800-692-7462
www.dpw.state.pa.us
State Pharmaceutical Department of Public Welfare Special Pharmaceutical Benefits
Assistance Pt•ogram Program
P.O. Box 8021
Harrisburg, PA 17105
Phone: 800-922-9384
http://www. dpw. state.pa.us/foradults/healthcaremedicalassistanc
e/aidswaiverprogram/specialpharmaceuticalbenefitsprogram/ind
ex.htrn
Rhode Island
Quality Improvement Rhode Island Quality Partners, Inc.
Organization 235 Promenade Street, Suite 500, Box 18
Pt•ovidence, RI 02908
Phone: 401-528-3200 / 800-662-5028
GRP 12 220 A 187 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Addendum A
www.riqualityp artners. or•g
State Health Insurance Senior Health Insurance Progt�am (SHIP)
Assistance Progr�am 74 West Road, Hazard Bldg.
Cranston, RI 02920
Phone: 401-462-4444
TTY: 401-462-0740
http://adr�c. ohhs.ri.gov
State Medical Assistance Department of Human Services of Rhode Island
Office 206 Elmwood Avenue
Providence, RI 02907
Phone: 401-462-5300
www.dhs.t�i.gov
State Pharmaceutical Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
Assistance Program - Attention RIPAE Rhode Island Department of Elder�ly Affairs
74 West Road, Hazard Building, Second Floor
Cranston, RI 02920
Phone: 401-462-3 000
TTY: 401-462-0740
http://www.dea. state.ri.us/programs/prescription_assist. php
South Carolina
Quality Improvement Carolina Center for Medical Excellence
Organization 246 Stoneridge Drive, Suite 200
Columbia, SC 29210
Phone: 803-251-2215 / 800-922-3089
www.thecarolinascentet�.org
State Health Insurance (I-CARE) Insurance Counseling Assistance and Refer•rals for
Assistance Program Ekiers
1301 Gervais Street, Suite 350
Columbia, SC 29201
Phone: 803-734-9900/800-868-9095
www.aging.sc.gov
State Medical Assistance South Carolina Department of Health and Human Seivices
Office P. O. Box 8206
Columbia, SC 29202-8206
Phone: 803-898-2500 / 888-549-0820
http://www.dhhs. state. sc.us
Tennessee
Quality Improvement Q Source
Organization 3175 Lenox Park Blvd., Suite 309
Meinphis, TN 38115
Phone: 901-682-0381 / 800-528-2655
www.qsource.org
State Health Insurance TN SHIP
Assistance Pt•ogram 500 Deaderick Street, Suite 825
Nashville, TN 37243-0860
Phone: 615-741-2056 / 877-801-0044
GRP 12 220 A 188 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Addendum A
TTY: 615-532-3893
www.state.tn.us/comaging/
State Medical Assistance Bureau of TennCare
Office 310 Great Circle Rd.
Nashville, TN 37243
Phone: 800-342-3145
TTY: 877-779-3103
http: //state.tn.us/tenncare
Texas
Quality Improvement TMF Health Quality Institute
Organization Bridgepoint I, Suite 300
5918 West Courtyard Drive
Austin, TX 78730-5036
Phone: 512-329-6610 / 800-725-9216
TTY: 877-486-2048
www.tmf.org
State Health Insm�ance Health Information Counseling and Advocacy Program (HICAP)
Assistance Program P.O. Box 149030
Austin, TX 78714-9030
Phone: 512-438-3011 / 800-252-9240
www.dads.state.�.us
State Medical Assistance Health and Human Services Commission of Texas
Office 4900 N. Lamar Blvd.
Austin, TX 78751-2316
Phone: 512-424-6500 ! 800-252-8263
http://www.hhsc. state.�.us
State Pharmaceutical Texas HIV State Pharmacy Assistance Program (SPAP)
Assistance Program P.O. Box 149347 ATTN: MSJA-MC 1873
Austin, TX 78714
Phone: 800-255-1090
http://www. dshs. state.�.us/hivstd/meds/spap. shtm
Vir inia
Quality Impt•ovement Virginia Health Quality Center
Organization 9830 Mayland Drive, Suite J
Richmond, VA 23233
Phone: 804-289-5320 ! 866-263-8402
TTY: 877-486-2048
www.vhqc.org
State Health Insurance Vu•ginia lnsurance Counseling and Assistance Program
Assistance Program (VICAP)
1610 Forest Avenue, Suite 100
Richmond, VA 23229
Phone: 804-662-9333 / 800-552-3402
TTY: 800-552-3402
www.vda.virginia.gov
State Medical Assistance Department of Medical Assistance Services
GRP 12 220 A 189 HMO EOC-with R7c (Y2013)
2013 Evidence of Coverage for Aetna Medicar•eSM Plan (HMO)
Addendum A
Office 600 East Broad Street
Richmond, VA 23219
Phone: 804-786-7933
TTY: 800-343-0634
http: Udmasva.dmas.virginia. govldefault. aspx
State Pharmaceutical Virginia HIV SPAP
Assistance Program P.O. Box 5930
Midlothin, VA 23112
Phone: 800-366-7741
http✓/www.vdh.virginia.gov/epidemiology/DiseasePrevention/spap.ht
m
Washin ton
Quality Improvement Qualis Health
Organization P.O. Box 33400
Seattle, WA 98133-0400
Phone: 206-364-9700 / 800-949-7536
TTY: 877-486-2048
www.QualisHealthMedicare.org
State Health Insurance Statewide Health Insurance Benefits Advisor•s (SHIBA) Helpline
Assistance Pt•ograin P.O. Box 40256
Olympia, WA 98504-0256
Phone: 800-562-6900
TTY: 360-586-0241
http: //www. insurance.wa. gov
State Medical Assistance Department of Social and Health Services of Washington
Office Office Building Two
14th and Jefferson Street
Olympia, WA 98504
Phone: 800-562-3022
www. ad sa. dshs.wa. gov
State Pharmaceutical Washington State Health Insurance Pharmacy Assistance
Assistance Program Program
P.O. Box 1090
Great Bend, KS 67530
Phone: 800-877-5187
https:/lwww.wship.otg/Default.as
West Virginia
Quality Improvement West Virgiilia Medical Institute, Inc;
Organization 3001 Chesterfield Avenue
Chat�leston, WV 25304
Phone: 304-346-9864/800-642-8686
www.wvini.org
State Health Insurance West Virguiia State Healtli Insurance Assistance Progratn (WV SHIP)
Assistance Program 1900 Kanawha Blvd. East
Charleston, WV 25345
Phone: 304-558-3317 / 877-987-4463
GRP_12 220 A 190 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Addendum A
www.wvship.org
State Medical Assistance West Virginia Department of Health & Human Resources
Office 350 Capitol Street, Room 251
Charleston, WV 25301
Phone: 304-558-1700 / 800-642-8589
http://www.dhhr.wv. gov/bms/
Wisconsin
Quality Improvement MetaStar, Inc.
Organization 2909 Landmark Place
Madison, WI 53713
Phone: 608-274-1940 / 800-362-2320
www.metastar.com
State Health Insurance Wisconsin SHIP (SHIP)
Assistance Progt�am 1 West Wilson Street
Madison, WI 53703
Phone: 608-267-3201 / 800-242-1060
TTY: 888-701-1251
www.dhfs. state.wi.us/aging/SHIP.htm
State Medical Assistance Wisconsin Department of Health
Ofiice 1 West Wilson Street
Madison, WI 53703
Phone: 608-266-1865 / 800-362-3002
TTY: 888-701-1251
http://www.dhfs. state.wi.us/medicaid/index.htm
State Pharmaceutical Wisconsin Chronic Renal Disease
Assistance Program P. O. Box 6410
Madison, WI 53716
Phone: 800-362-3002 / 800-947-9627
https://www. forwardhealth.wi.gov/WIPortal/Tab/42/icscontent/p
rovider/wcdp/index.htm. spage
GRP 12 220 A 191 HMO EOC-with F� (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Multi-language Intet•preter Setvices
Multi-language Interpreter Services
English: We have free interpreter services to answer any questions you may have about our
health or drug plan. To get an interpt•eter, just call us at 1-888-267-2637. Someone who speaks
English/Language can help you. This is a free service.
Spanish: Tenemos servicios de interprete sin costo alguno para responder cualquier pregunta
que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un interprete, por
favor• llame al 1-888-267-2637. Alguien que hable espanol le podr�a ayudar. Este es un servicio
gratuito.
Chinese Mandarin: �'c'�17�'(��',��J�i����; , ��J1� � A �`c��f�°�G��JJ'(��.1�J'��'�
�Ip�o #tp��� ��Ji��Ai���� , i��t�,1-888-267-26370 �'c�17�J�'�=�'���� f&�� �
�,o x —i�i����� o
rs �(;-� J� � J. �. �
Chinese Cantonese:
�Lr,��J7�41���� I7�/%J`c�=N71c�%J ITI'M�'.1 �ei I J �J���p� � h��:1.LLl.i7N���Jl�1�JL��� J���P�/J��77o J�{-! 77�JJC7�/J��
, p�tSZ�I-888-267-26370 ����p�����J.�����,���:#�����o ��—I�������o
Tagalog: Mayroon kaming libreng set•bisyo sa pagsasaling-wika upang masagot ang anumang
mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggatnot. Upang tnakakuha
ng tagasaling-wika, tawagan lamang kami sa 1-888-267-2637. Maaari kayong tulungan ng isang
nakakapagsalita ng Tagalog. Ito ay libreng serbisyo.
French: Nous proposons des setvices gratuits d'interpretation pour repondre a toutes vos
questions relatives a notre regime de sante ou d'assurance-medicaments. Pour acceder au service
d'interpretation, il vous suffit de nous appeler au 1-888-267-2637. Un interlocuteur �arlant
Fran�ais pourra vous aidet�. Ce service est gratuit.
Vietnamese: Chung toi co dich vu thong dich mien phi c�e tra lo�i cac cau hoi ve chuo•ng sirc
khoe va chuo�g trinh thuoc men. Neu qui vi can thong dich vien xiu goi 1-888-267-2637. se co
nhan vien noi tieng Viet giup c�o• qui vi. �ay la dich vu mien phi .
German: Unser kostenloser polmetscherservice beantwortet Ihren Fragen zu unserem
Gesundheits- und Arzneunittelplan. Unset�e Dolnietscher eri•eichen Sie unter 1-888-672-2637.
Man wi�•d Ihnen dort auf Deutsch weiterhelfen. Dieset� Service ist kostenlos.
Korean' o �� � Q i � O k q d s L L �) � aF o C�L" �� T`-�7- o�
. � _ � - oi -E oil -H _ I �
�-Id� �� �jlo�E� °�a�l�E. o � �-1d1�� olo�Ez�°� L�sEI-800-594-9390di��
L°I�H T��I�I�. �F�o�� �FL A�OF�E�E �QE ��I ��b�I�E. oI �-IdI-�L T��
� o �i �-I Cf .
GRP_12 220 A 192 HMO EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Multi-language Interpreter Services
Russian: EcnH y Bac BosxH�cFiy�r Bonpocbi oTxocHTenbxo cTpaxosoro HnH MeAKxaMexTxoro
rrnaxa, Bbr tv�o�eTe BocnonbsoBaTbcx xau1HMK 6ecnnaTxbrMH ycnyraMK nepeBoR�rHxos. LITo6br
Bocrto.�bsoBaTbcx ycrryraNrH nepeBoA�Hxa, nosBoxKTe xaM r�o Tenec�oxy 1-888-267-2637. BaM
oxaxceT noMou�b coTpyAxKx, xoTopbiH roBopHT no-pycc�. Aaxxax ycnyra 6ecnnaTxax.
Arabic• v�:� ��s�s� �.� � �.s.�t► .��1 �,,�yi �,.� ,i :�.ol� �l,.:t, al�i �1 � a��:U :,�,�1i ��s�1i ��ti �t�� �.�; �;:,i
a�,y�11 ��.:�,, L< �y� �� .6635-282-008-1 � t�, ��yi sy� ��,t�.o aA.� a:La .�L;.�t...�,�,,
Italian: E disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande
sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-888-267-
2637. Un nostro incaricato che parla Italiano vi fornira 1'assistenza necessaria. E un servizio
gratuito.
Portugues: Dispomos de servi�os de interpreta�ao gratuitos para r�esponder a qualquer questao
que tenha acerca do nosso plano de saude ou de medica�ao. Para obter um interprete, contacte-
nos atraves do numero 1-888-267-2637. Ira encontrar alguem que fale o idioma Portugues para
o ajudar. Este seivi�o e gratuito.
French Creole: Nou genyen sevis entepret gratis pou reponn tout kesyon ou ta genyen
konsenan plan medikal oswa dwog nou an. Pou jwenn yon entepret, jis rele nou nan 1-888-267-
2637. Yon moun ki pale Kreyol kapab ede w. Sa a se yon sevis ki gratis.
Polish: Umozliwiarny bezp�atne skorzystanie z uskug tlumacza ustnego, ktory pomoze w
uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania lekow. Aby skorzystac z
pomocy t�umacza znaj�cego j�zyk polski, nalezy zadzwonic pod numer 1-888-267-2637. Ta
uskuga jest bezpYatna.
� > > _ ._ � .• _ � . .. a�
�
� o� . _ iii • • � . .�� � � �
� .�
� � €` - 'E` - � . ■ ■
��-7' `������i��-��.�%���� A �.�-�����, �,,. �,J���--���J'�� �� �-�-c_-�c�
t,��7"o 7�aR��=� �G�t��a �.6�. 1-888-267-2637 6�� ��«� l,�o
� �`� x#� l,� �'` l, � �" o �. �. G� �,,. � � — �' Z Z �" o
F--I � A � � � �
GRP 12 220 A 193 HMO EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Notes
NoteS
GRP 12_220 A 194 HMO EOC—with R7c (Y2013)
2413 Evidence of Coverage for Aetna MedicareSM Plan (HMO)
Notes
Aetna Medicare Member Services
CALL
TTY
��
Please call the telephone number pt�inted on the back of your
member ID card. Or for questions regarding your medical
benefits, call our general customer service center at 1-888-267-
2637. For questions regarding your prescription drug
benefits, call 1-800-594-9390.
Calls to these numbers are free. Hours of operation: Monday
through Friday, 8 a.m. to 6 p.m. in all time zones.
Member Services also has free language interpreter services
available for non-En�lish speakers.
711
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.
Calls to this number are free. Hours of operation: Monday through
Friday. 8 a.m. to 6 p.m. in all time zones.
Aetna Medicare
P.O. Box 14088
KY 40512-4088
WEBSITE
://www
.com
State Health Insurauce Assistance Program
SHIP is a state pt•ogram that gets money fi•om the federal government to give free local
health insurance counseling to people with Medicare. Contact information for your state's
SHIP is on Addendum A in this Evidence of Coverage.
• � '.
� �
GRP 12 220 A 195 HMO EOC-with I� (Y2013)
Aetna Medicaresni Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
AETNA HEALTH INC.
EXHIBIT C
Contract Holder Name: City Of Fort Worth
Contract Holder Group Agreement Effective Date: January 1, 2013
Contract Holder Number: 457106
This Medical Benefits Chart is part of the Evic�ence of Coverage for Aetna Medicare Plan
(HMO). When the Evidence of Coverage refers to the attachment for information on health cat•e
benefits covered under our plan, it is referring to this Medical Benefits Chart. (See Chapter 4,
Medical Benefits Chart (what is covered and what you pay).
Deductible
This is the amount you have to pay out of pocket before the
plan will pay its share for your covered medical setvices.
'� 1
Annual Maacimum 0ut-of:Pocket limit
The maxirnum out-of-pocket limit applies to all covered In-network maximum out-of-
Medicare benefits including deductible pocket amount:
'� 1
GRP_12 219/220/221 A H4523 1 ME HMO SCH COPAY (Y2013)
Aetna MedicareS�'I Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
You will see this apple next to the preventive services in the benefits chart.
� � .� �
A one-time screening ultrasound for people at risk. The plan
only covers this screening if you get a referral for it as a
result of your "Welcome to Medicare" preventive visit.
$0 copay
Ambulance servicesX
• Covered ambulance services include fixed wing, $0 copay for• each Medicare-
rotary wing, and ground ambulance set•vices, to the covered ambulance benefit
nearest appt�opriate facility that can provide car�e (one way)
only if they are furnished to a member whose
medical condition is such that other means of
GRP 12 219/220/221 A H4523 2 ME HMO SCH COPAY (Y2013)
Aetna MedicareSn� Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
Services that are covered for you What you must pay (after
deductible)"when you get these
' services
transportation are contraindicated (could endanger
the person's health) or• if authorized by the plan.
The member's condition must require both the
ambulance transportation itself and the level of
service provided in order for the billed service to be
considered medically necessary.
Non-emergency transportation by ambulance is
appropriate if it is documented that the inember's
condition is such that other means of transportation
are contraindicated (could endanger the person's
health) and that transpor-tation by ambulance is
rnedically requir�ed.
Round trip transport applies for each Medicare
covered ambulance transport to a physician office or
dialysis visit.
*Pr•ior authorization rules apply for air ambulance transfers
and non-emergency transportation by ground ambulance or
medical van.
�
If you've had Part B for longer than 12 months, you can get
an annual wellness visit to develop or� update a personalized
prevention plan based on your current heaith and risk
factors. This is covered once eveiy 12 months.
Note: Your fiist annual wellness visit can't take place
within 12 months of your "Welcome to Medicare"
preventive visit. However, you doii't need to have had a
"Welcorne to Medicare" visit to be covet�ed foi• annual
wellness visits after you've had Part B for 12 months.
There is no coinsurance,
copayment, or deductible for
the annual wellness visit.
GRP_12 219/220/221 A H4523 3 ME HMO SCH COPAY (Y2013)
Aetna Medicaresn'I Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
:��
For qualified individuals (generally, this means people at
risk of losing bone mass or at risk of osteoporosis), the
following services are covered every 24 months or more
frequently if inedically necessary: procedures to identify
bone mass, detect bone loss, or determine bone quality,
including a physician's interpretation of the results.
Breast cancer screening (mammograms)
Covered services include:
• One baseline mammogram between the ages of 35
and 39
• One screening tnammograin every 12 months for
women age 40 and older
• Clinical breast exams once every 24 months
Cardiac i•ehabilitation services
Comprehensive programs of cardiac t•ehabilitation services
that include exercise, education, and counseling are covered
for members who meet certain conditions with a doctor's
referral. The plan also covers intensive cardiac
rehabilitation programs that are typically more rigorous or
mor•e intense than cardiac rehabilitation programs.
$0 copay
$0 copay
$0 copay for each Medicare-
covered car•diac rehabilitaiion
services visit
Cardiovascular disease rislc reduction visit (therapy $0 copay
for cardiovascular disease)
We cover 1 visit per year with your primary care doctor to
help lower your risk for cardiovascular disease. During this
visit, your doctor may discuss aspu in use (if appropriate),
check your blood pressure, and give you tips to make sure
you're eating well.
GRP 12 219/220/221 A H4523 4 ME HMO SCH COPAY (Y2013)
Aetna MedicareSnl Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
Services that are covered for you What you must pay (after
deductible) when you get these
setvices
Cardiovascular disease testing
Blood tests for the detection of cardiovascular disease (or
abnormalities associated with an elevated risk of
cardiovascular disease) once every 5 years (60 months).
. , ,. .� . .. ,,
Covered services include:
For all women: Pap tests and pelvic exams are covered once
every 12 months
Chiropractic services
$0 copay
$0 copay
Covered services include: $0 copay per Medicare-
• We cover only manual manipulation of the spine to covered visit
correct subluxation
� � � �
For people 50 and older, the following are covered:
• Flexible sigmoidoscopy (or screening barium enema
as an alternative) evety 48 months
• Fecal occult blood test, every 12 months
For people at high risk of colorectal cancer, we cover:
• Screening colonoscopy (or screening barium enema
as an alternative) evei•y 24 months
For� people not at high risk of colorectal cancer, we cover�:
• Screening colonoscopy every 10 years (120
months), but not within 48 months of a screening
sigmoidoscopy
$0 copay
GRP_12 219/220/221_A H4523 5 ME HMO SCH COPAY (Y2013)
Aetna MedicareSM Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
es that are covered for you
`�� � 1•� • �i •• ��
We cover 1 screening for depression per year.
screening must be done in a primaiy care setting that
provide follow-up treatment and refet•rals.
1 � i�
We cover this screening (includes fasting glucose tests) if
you have any of the following risk factors: high blood
pressut•e (hypertension), history of abnormal cholesterol and
triglyceride levels (dyslipidemia), obesity, or a histoiy of
high blood sugar (glucose). Tests may also be covered if
you meet other t•equirements, like being overweight and
having a family history of diabetes.
Based on the results of these tests, you may be eligible for
up to two diabetes screenings eveiy 12 months.
Diabetes self-management training, diabetic services
and supplies
For all people who have diabetes (insulin and non-insulin
users). Covered services include:
• Supplies to monitor your blood glucose: Blood
glucose monitor, blood glucose test strips, lancet
devices and lancets, and glucose-control solutions
for checking the accuracy oftest strips and monitors
Fol• people with diabetes who have severe diabetic
foot disease: One pait• per calendar year of
therapeutic custom-molded shoes (including inserts
provided with such shoes) and two additional pairs
of inserts, or one pai�� of depth shoes and three pait•s
of inserts (not including the non-customized
removable inserts pr�ovided with such shoes).
Coverage includes fitting.
The
�
$0 copay
$0 copay
$0 copay for
covered services
Medicat•e-
GRP 12 219/220/221 A H4523 6 ME HMO SCH COPAY (Y2013)
Aetna MedicareS�i Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
• Diabetes self-management training is covered under
certain conditions
Durable medical equipment and related suppliesx
(For a definition of "durable medical equipment," see
Chapter 10 of this booklet.)
Covered items include, but are not litnited to: wheelchairs,
crutches, hospital bed, IV infusion pump, oxygen
equipment, nebulizer, and walker.
We cover all medically necessary durable medical
equipment covered by Original Medicare. If our supplier in
your at�ea does not carry a particular brand or manufacturer,
you may ask them if they can special order it for you.
*Prior authorization iules apply for certain services; contact
Member Services for information.
Emergency care
Emergency care refers to services that are:
• Furnished by a provider qualified
emergency services, and
• Needed to evaluate or stabilize an
medical condition.
$0 for each Medicare cover•ed
item
to furnish $0 copay for each Medicare-
covered emergency room visit
emergency
A medical emergency is when you, or any other prudent
layperson with an average knowledge of health and
medicine, believe that you have medical symptoms that
requu•e immediate medical attention to prevent loss of life,
loss of a limb, ot� loss of function of a limb. The medical
syinptotns may be an illness, injuty, severe pain, or a
medical condition that is quickly getting worse.
This covei•age is available world-wide.
If you are immediately
admitted to the hospital, you
pay $0 for the einergency
room visit
If you receive emergency cat•e
at an out-of-network hospital
and need inpatient car•e after
your emergency condition is
stabilized, you must move to a
network hospital in ot�det• to
pay the in-network cost-
sharing amount for the part of
GRP_12 219/220/221 A H4523 7 ME HMO SCH COPAY (Y2013)
Aetna MedicareSM Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
your stay after you are
stabilized. If you stay at the
out-of-network hospital, your
stay will be covered but you
will pay the out-of-network
cost-sharing amount for the
part of your stay after you are
stabilized.
�.�� �• •� � � ��
i. ��i• � 1. •-• • �.
�
� �� • • �- � � -�
� •• . • • - i • • � •
- � • .�• • • .�- • •
• � • . �. • •• -�
, � I� •-• •
�. , ..._ w _ � .. . ,. �
. . . . . ,
. . . .
-
� -� • � • • • •
� � • -� .�- •
••� • � • -� • •
�- �
�. , �-� • � .
• - • -
i � i
• . -. - -� � • . �. �. �-� • � .
.�• -� • • -�
. � • •
� �� ' �� �
-. • . � - • � - � • �-• • � .
- •- • • � � - • . �- -
�; .
. • .. �.
GRP 12 219/220/221 A H4523 8 ME HMO SCH COPAY (Y2013)
Aetna MedicareSn'` Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
Services that are covered for you
• Telemonitoring for hypertension
This program is designed to help you manage your
high blood pressure. You will receive a free
automatic blood pressure monitor, education
material and support on how to control your blood
pressure.
Hearing services
• Diagnostic hearing and balance evaluations
performed by your pt�ovider to determine if you need
medical treatment are covered as outpatient care
when furnished by a physician, audiologist, or other
qualified provider.
• Our plan covets one routine hearing exam every 12
months
Hearing aid reimbursement (A Statement of Satisfaction
Foi•m must be signed by the member and the provider and
submitted to HMO to obtain reimbursement. Contact
Member Seivices to obtain this form.) Amounts you pay
for hearing aids do not count toward your• annual maximum
out-of-pocket amount.
.� �,
• -•. - • . •
-. • •
sct�eening test ot� who are at
we cover:
• One sct•eening exam every 12 months
For women who are pregnant, we cover:
• Up to three screening exams during a pregnancy
Home health agency careX
�. � �� � �.
�-• � - �-� • �- i- -
�-. • • .
$0 copay for basic hearing
evaluations
$0 copay for one routine
hearing exam every 12 months
Our plan reimbur�ses
evety 36 months
$0 copay
$2,000
$0 for each Medicare-covered
GRP_12 219/220/221 A H4523 9 ME HMO SCH COPAY (Y2013)
Aetna MedicareSA' Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
Prior to receiving home health services, a doctor
certify that you need home health services and will
home health services to be provided by a home
agency.
must home health visit, plus
order applicable DME cost sharing
health for any covered supplies
Covered services include, but are not limited to:
• Part-time or intermittent skilled nursing and home
health aide services (To be covered under the home
health care benefit, your skilled nursing and home
health aide services combined must total fewer than
8 hours per day and 35 hours per week)
• Physical therapy, occupational therapy, and speech
therapy
• Medical and social services
• Medical equipment and supplies
*Prior authorization rules apply.
Hospice care
You may receive care fi•om any Medicare-certified hospice
program. Your hospice doctor can be a network provider or
an out-of-network provider.
Covered services include:
• Drugs for symptom control and pain relief
• Short-term respite care
• Home care
For hos�pice services and for services that are covered bv
Medicare Part A or B and ar•e related to your terminal
condition: Original Medicare (rather than our plan) wili pay
for your hospice services and any Part A and Part B
services related to your terminal condition. While you are in
the hospice program, youi� hospice provider will bill
Original Medicare for• the services that Original Medicare
pays for.
When you enroll
Medicare-certified
tTi�s�
hospice
program, your hospice services
and yout� Part A and Part B
services related to your
terminal condition are paid for
by Original Medicare, not our
plan.
GRP 12 219/220/221 A H4523 10 ME HMO SCH COPAY (Y2013)
Aetna MedicareShf Plan (HMO)
2013 Medical Benefits Chart (5chedule of Copayments/Coinsurance)
For services that are covered by Medicare Part A or B and
at•e not related to your terminal condition: If you need non-
emergency, non-urgently needed services that at•e covered
under Medicare Par-t A or B and that are not related to your
terminal condition, your cost for these services depends on
whether you use a provider in our plan's network:
• If you obtain the covered setvices from a network
provider, you only pay the plan cost-sharing amount
for• in-network services
• If you obtain the covered setvices from an out-of-
network provider, you pay the cost sharing under
Fee-for-Service Medicare (Original Medicare).
However, a$er• payment, you can ask us to pay you
back for the difference between the cost sharing in
our plan and the cost sharing under Original
Medicare.
For services that are covered bv our plan but are not
covered bv Medicat�e Part A or B: Our plan will continue to
cover plan-covered setvices that are not covered under Part
A or B whether or not they are related to your terminal
condition. You pay your plan cost sharing amount for these
seivices.
Note: If you need non-hospice care (care that is not related
to your tet•minal condition), you should contact us to
arrange the services. Getting your non-hospice care tl�•ough
our networlc providers wi11 lower your sllare of the costs for
the services.
Our plan covers hospice consultation services for a
terminally ill person who hasn't elected the hospice benefit.
Paliiative care consultation is also available.
Immunizations
Covered Medicare Part B services include:
• Pneumonia vaccine
Included service in Inpatient
hospital care; Physician
services cost shar•ing applies
for outpatient consultations
$0 copay
No referral needed
GRP_12 219/220/221 A H4523 I 1 ME HMO SCH COPAY (Y2013)
Aetna Medicares�f Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
• Flu shots, once a yeaf• in the fall or winter
• Hepatitis B vaccine if you are at
intermediate risk of getting Hepatitis B
• Other vaccines if you are at t•isk and
Medicare Part B coverage rules
Inpatient hospital care*
high or I Office visit copay may apply
they meet
There is no limit to the number of days covered by the plan
for each hospital stay. Covered selvices include:
• Semi private room (or a private room if inedically
necessary)
• Meals including special diets
• Regular nursing services
• Costs of special care units (such as intensive care or
coronaty care units)
• Drugs and medications
• Lab tests
• X-rays and other radiology services
• Necessary surgical and medical supplies
• Use of appliances, such as wheelchairs
• Operating and recovery room costs
• Physical, occupational, and speech language therapy
• Inpatient substance abuse setvices
• Under certain conditions, the following types of
transplants are covered: corneal, kidney, kidney-
pancreatic, heart, liver, lung, heart/lung, bone
marrow, stem cell, and intestinaUmultivisceral. If
you need a transplant, we will arrange to have your
case reviewed by a Medicare-approved transplant
center that will decide whether you at�e a candidate
for a transplant. Transplant providers may be local
or outside of the service at�ea. If local transplant
providers are willing to accept the Original
Medicare rate, then you can choose to obtain your
transplant services locally ot• at a distant location
offered by the plan. If our plan provides transplant
services at a distant location (outside of the seivice
area) and you chose to obtain transplants at this
For Medicare-covered hospital
stays, you pay:
$0 copay per admission
If you get authorized
inpatient care at an out-of-
network hospital after your
emergency condition is
stabilized, your cost is the
highest cost sharing you
would pay at a network
hospital.
GRP 12 219/220/221 A H4523 12 ME HMO SCH COPAY (Y2013)
Aetna Medicaresnt Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
ed for you
d
s
distant location, we will arrange or pay for
appropriate lodging and transportation costs for you
and a companion. If you choose to obtain any
transplant services that are covered by our plan fi•om
a Medicare-approved transplant center or facility
that does not participate in our plan's Institutes of
ExcellenceTM network, we will not arrange ot• pay
for lodging or transportation costs for you or your
companion. A complete list of Medicare-approved
transplant centers and facilities that participate in
our Plan's Institutes of Excellence network can be
found in the Provider Directory and on out� website
at www.aetnaretireeplans.com.
Blood - including storage and administration.
Coverage of whole blood and packed red cells
begins only with the fourth pint of blood that you
need — you must either� pay the costs for the first 3
pints of blood you get in a calendar year or have the
blood donated by you or someone else. All other
components of blood are covered beginning with the
first pint used.
Physician seivices
Note: To be an inpatient, your provider must write an ot�der
to admit you formally as an inpatient of the hospital. Even if
you stay in the hospital overnight, you might still be
considered an "outpatient." If you are not sm�e if you are ail
inpatient or an outpatient, you should ask the hospital staff.
You can also find more information in a Medicare fact sheet
called "Are You a Hospital Inpatient or Outpatient? If You
Have Medicare — Ask!" This fact sheet is available on the
Web at
http://www.medicaregov/Publications/Pubslpdf/11435.pdf
or by calling 1-800-MEDICARE (1-800-633-4227). TTY
users call 1-877-486-2048. You can call these numbels for
fi�ee, 24 hours a day, 7 days a week.
What you must pay (after
eductible) when, you get these
ervices
GRP_12 219/220/221 A H4523 13 ME HMO SCH COPAY (Y2013)
Aetna MedicareSA` Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
*Prior authot•ization rules apply.
Inpatient mental health care*
• Covered setvices include mental health care services
that require a hospital stay.
*Prior authorization rules apply.
Inpatient services covered during a non-covered
inpatient stay
If you have e�austed your inpatient benefits or if the
inpatient stay is not reasonable and necessaty, we will not
cover your inpatient stay. However, in some cases, we will
cover certain setvices you receive while you are in the
hospital or the skilled nursing facility (SNF) stay. Covered
services include, but are not limited to:
• Physician seivices
• Diagnostic tests (like lab tests)
• X-ray, radium, and isotope therapy including
technician materials and services
• Surgical dressings
• Splints, casts and other devices used to reduce
fractures and dislocations
• Prosthetics and orthotics devices (other than dental)
that replace all or part of an internal body organ
(including contiguous tissue), or all or part of the
function of a permanently inoperative or
malfunctioning internal body organ, including
replacement or repau�s of such devices
• Leg, arm, back, and neck braces; trusses, and
artificial legs, arms, and eyes including adjustments,
t•epairs, and replacements required because of
breakage, wear, loss, or a change in the patient's
physical condition
• Physical therapy, speech therapy, and occupational
therapy
For Medicare-covered
hospital stays, you pay:
$0 copay per admission
You are covered for these
services according to
Medicare guidelines.
You pay applicable
copayments or coinsurance
listed in this Benefits Chart
for covered services received.
GRP 12 219/220/221 A H4523 14 ME HMO SCH COPAY (Y2013)
Aetna MedicareSnl Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
Services that are covered for you
Medical nutrition therapy
This benefit is for people with
disease (but not on dialysis), or
when referred by your doctor.
diabetes, renal (kidney)
after a kidney tr�ansplant
We cover 3 hours of one-on-one counseling services during
your first year that you receive medical nutrition thet�apy
services undet• Medicare (this includes our plan, any other
Medicare Advantage plan, or Original Medicat•e), and 3
hours each year aftet� that. If your condition, treatment, or
diagnosis changes, you may be able to receive more hours
of treatment with a physician's r•efel•ral. A physician must
prescribe these services and renew their referral yearly if
your treatment is needed into the next calendar year.
�. � �,
�-� • - � .-
��1 ���.
GRP_12 219/220/221_A H4523 15 ME HMO SCH COPAY (Y2013)
Aetna Medicaresnt Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
Services that are covered for you What you must pay (ai�er
deductible) when you get these
services '
Medicare Part B prescription drugs
These drugs are covered under Part B of Original Medicare.
Members of our plan receive coverage for these drugs
tht•ough our plan. Covered drugs include:
• Drugs that usually aren't self-administered by the
patient and are injected or infused while you are
getting physician, hospital outpatient, or ambulatoiy
surgical center services
• Drugs you take using durable medical equipment
(such as nebulizers) that were authorized by the plan
• Clotting factors you give yourself by injection if you
have hemophilia
• Immunosuppressive Drugs, if you were enrolled in
Medicare Part A at the time of the organ transplant
• Injectable osteopot•osis drugs, if you are
homebound, have a bone fracture that a doctor
certifies was related to post-menopausal
osteoporosis, and cannot self-administer the drug
• Antigens
• Certain oral anti-cancer drugs and anti-nausea drugs
• Certain drugs for home dialysis, including heparin,
the antidote for heparin when medically necessary,
topical anesthetics, and erythropoisis-stimulating
agents (such as Epogen0, Procrit0, Epoetin Alfa,
Aranesp0, or Darbepoetin Alfa)
• Intravenous Immune Globulin for the home
treatment of primary immune deficiency disease
$0 copay per pr•escription or
refill
Obesity screening and therapy to promote sustained $0 copay
weight loss
If you have a body mass index of 30 or more, we cover
intensive counseling to help you lose weight. This
counseling is covered if you get it in a primary care setting,
where it can be coordinated with your comprehensive
prevention plan. Talk to your primary care doctor or
GRP 12 219/220/221 A H4523 16 ME HMO SCH COPAY (Y2013)
Aetna MedicareSn'I Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
Services that are covered for you What you must pay (after
' deductible) when you get these
' services
practitioner to find out more.
Outpatient diagnostic tests and therapeutic services and Your cost share is based on:
supplies* - the tests/services/supplies
Covered services include, but are not limited to:
• Medicare covered routine X-rays
• Radiation (radium and isotope) thet�apy including
technician materials and supplies
• Diagnostic Radiology and coinplex imaging such as:
MRI, MR.A, PET scan
• Sur•gical supplies, such as dressings
• Splints, casts and other devices used to reduce
fi�actures and dislocations
• Laboratory tests
• Home PT/INR monitoring is covered for clu�onic,
oral anticoagulation management for members on
warfarin with mechanical heart valves, chronic atrial
fibrillation, or venous tlu�omboembolism (inclusive
of deep venous thrombosis and pulmonary
�
embolism). The monitor and the home testing are
covered for members who meet certain conditions
and when it is prescribed by a doctor treating their
condition.
Blood. Coverage begins with the fourth pint of
blood that you need — you must either pay the costs
for the fn•st 3 pints of blood you get in a calendar
year or have the blood donated by you or someone
else. Coverage of storage and adtninistration begins
with the first pint of blood that you need.
Other outpatient diagnostic tests
*Prior authorization rules apply fot• certain services; please
contact Member Setvices for infor�mation.
you receive
- the provider of the
tests/services/supplies
- the setting where the
tests/services/supplies ar�e
performed.
$0 for primary care doctor
visits for Medicare-covered
benefits
$0 for specialist visits for
Medicare-covered benefits
$0 for Medicare-covered
routine X-rays
$0 for Medicat�e-covet•ed
diagnostic radiology and
complex imaging services
$0 for� Medicare-covered lab
services
$0 for Medicare-covered
diagnostic procedures or tests
$0 for Medicare-covered
therapeutic radiology services
$0 copay for Medicare-
covered medical supply items
$0 for Medicare-covered
GRP_12 219/220/221 A H4523 17 ME HMO SCH COPAY (Y2013)
Aetna Medicares�� Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
r you
Home INR monitor/tests
$0 copay for blood a$er the
first 3 unr•eplaced pints�'
Outpatient hospital services
Your cost share is based on:
We cover medically-necessary services you get in the
outpatient department of a hospital for diagnosis ot•
treatment of an illness or injuiy.
Covered services include, but are not limited to:
• Services in an emergency department or outpatient •
clinic, such as observation services or outpatient
surgery
• Laboratory and diagnostic tests billed by the
hospital
• Mental health care, including care in a partial-
hospitalization program, if a doctor certifies that
inpatient treatment would be requu•ed without it
• X-rays and other radiology services billed by
hospital
• Medical supplies such as spiints and casts
• Certain screenings and preventive setvices
• Certain drugs and biologicals that you can't
yourself
the
give
Note: Unless the provider has written an oyder to admit you
as an inpatient to the hospital, you are an outpatient and pay
the cost-sharing amounts for outpatient hospital services.
Even if you stay in the hospital overnight, you might still be
considered an "outpatient." If you are not sure if you ar•e an
outpatient, you should ask the hospital staff.
You can also find more information in a Medicare fact
sheet called "Are You a Hospital Inpatient or
Outpatient? If You Have Medicare — Ask!" This fact
sheet is available on the Web at
http://www.medicare.gov/Publications/Pubs/pdf/1143 S.p
�s `
the
tests/set•vices/supplies
you receive
the providet• of the
tests/services/supp lies
the setting where the
testslset•vices/supplies
are performed.
If you receive multiple services
in one visit, you generally pay
only the cost sharing of the
highest-cost setvice.
Please refer to the following
sections in this benefits chart
for more information:
• Outpatient surgery,
including services
provided at hospital
outpatient facilities
and ambulatory
surgical centers
• Outpatient diagnostic
tests and therapeutic
ser•vices and supplies
GRP 12 219/220/221 A H4523 18 ME HMO SCH COPAY (Y2013)
Aetna MedicareS"I Plan (I�MO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
Services that are covered for you ' What you must pay (after
deductible) when you get these
services
df or by calling 1-800-MEDICARE (1-800-633-4227).
TTY users call 1-877-486-2048. You can call these
numbers for free, 24 hout�s a day, 7 days a week.
Outpatient mental health care
Covered seivices include:
Mental health services provided by a state-licensed
psychiatrist or doctor, clinical psychologist, clinical social
worker, clinical nut•se specialist, nurse practitioner,
physician assistant, at other Medicare-qualified mental
health care professional as allowed under applicable state
laws.
Outpatient rehabilitation services
Covered services include: physical therapy, occupational
therapy, and speech language thet•apy.
Outpatient rehabilitation services are provided in various
outpatient settings, such as hospital outpatient depai�tments,
independent therapist offices, and Comprehensive
Outpatient Rehabilitation Facilities (CORFs).
Outpatient substance abuse services
Outpatient surgery*, including services provided at
hospital outpatient facilities and ambulatory surgical
centers
Note: If you are having surgety in a hospital facility, you
should check with your provider about whether you will be
an inpatient or outpatient. Unless the provider writes an
order to adrnit you as an inpatient to the hospital, you are an
$0 copay for each Medicare-
covered individual or group
therapy visit
$0 copay for each Medicare-
covered outpatient
rehabilitation service visit
$0 copay for each Medicare-
covered individual or group
therapy visit
Your cost share is based on:
- the tests/services/supplies
you t�eceive
- the provider of the
tests/services/supplies
- the setting where the
tests/servicesfsupplies are
perfor•med.
GRP_12 219/220/221 A H4523 19 ME HMO SCH COPAY (Y2013)
outpatient and pay the cost-sharing amounts for outpatient
surgeiy. Even if you stay in the hospital overnight, you
might still be considered an "outpatient."
If you receive multiple
services in one visit, you
generally pay only the cost
sharing of the highest-cost
service.
*Prior authorization rules apply for� certain services; contact
Member Setvices for information. $0 for Medicare-covered
outpatient hospital facility
visits
$0 for ambulatory surgical
center visits
Partial hospitalization services
"Partial hospitalization" is a structttred progt�am of active
psychiatric treatment provided in a hospital outpatient
setting or by a community mental health center, that is more
intense than the care received in your doctor's or• therapist's
office and is an alternative to inpatient hospitalization.
Physician/Practitioner services, including doctor's ofiice
visits
Covered set•vices include:
• Medically-necessar�y medical care or surgical
services furnished in a physician's office, certified
ambulatory surgical center, hospital outpatient
department, walk-in clinic, (non-urgent) or any other�
location
• Consultation, diagnosis, and treatment by a
specialist
• Basic hearing and balance exams performed by your
PCP or specialist, if your doctoY• ordets it to see if
$0 copay for each Medicare-
covered visit
Yout• cost share is based on:
• the
tests/services/suppl ies
you receive
• the provider of the
tests/services/supplies
• the setting where the
tests/services/supplies
are performed.
$0 copay for each primaty care
doctor visit for Medicare-
GRP 12 219/220/221 A H4523 20 ME HMO SCH COPAY (Y2013)
Aetna Medicares"'` Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
Aetna MedicareS"I Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
Services that are covered for you, What you must pay (after
deductible) when you get these
services
you need medical treatment
• Telehealth services including consultation,
diagnosis, and treatment by a physician or
practitionet• for patients in certain rural areas or
other locations approved by Medicare
• Second opinion by another network provider prior to
surgery
• Non-routine dental cat•e (covered services are
limited to surgery of the jaw or related structut•es,
setting fractures of the jaw or facial bones,
extraction ofteeth to prepare the jaw for radiation
treatments of neoplastic cancer disease, or services
that would be covered when pr•ovided by a
physician)
Podiatry services
Covered services include:
• Diagnosis and the medical or surgical treatment of
injuries and diseases of the feet (such as hammer toe
or heel spurs).
Routine foot car�e for members with certain medical
conditions affecting the lower liinbs
�� ,
For rnen age 50 and older, covet•ed services include the
following - once every 12 months:
• Digital rectal exazn
• Prostate Specific Antigen (PSA) test
Prosthetic devices and related supplies*
Devices (other than dental) that replace all or part of a body
covered benefits
$0 copay for each specialist
visit for Medicare-covered
benefits
$0 for each Medicare covered
dental service
$0 for each Medicare-covered
visit
$0 copay
$0 for each Medicare covered
item
GRP_12 219/220/221 A H4523 21 ME HMO SCH COPAY (Y2013)
Aetna MedicareSM Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
part or function. These include, but are not limited to:
colostomy bags and supplies directly related to colostomy
care, pacemakers, braces, prosthetic shoes, artificial limbs,
and breast prostheses (including a surgical brassiere after a
mastectomy). Includes certain supplies related to prosthetic
devices, and repair and/or replacement of prosthetic
devices. Also includes some coverage following cataract
removal or cataract surgery— see "Vision Care" later in this
section for more detail.
*Prior authorization rules apply for certain services; please
contact Member Services for information.
Pulmonary rehabilitation services
Comprehensive programs of pulmonary rehabilitation are
covered for members who have moderate to vely severe
clu�onic obstructive pulmonary disease (COPD) and a
referral for pulmonary rehabilitation fiom the doctor
treating their chronic respiratoiy disease.
�i � � � i � � •� � �
We cover one alcohol misuse screening for adults with
Medicare (including pregnant women) who misuse alcohol,
but aren't alcohol dependent.
If you screen positive for alcohol misuse, you can get up to
4 brief face-to-face counseling sessions per year (if you're
competent and alert during counseling) provided by a
qualified primary car•e doctor or practitioner in a prunary
care setting.
$0 copay for each Medicare-
covered pulmonary
rehabilitation services visit
$0 copay
Screening for sexually transmitted infections (STIs) $0 copay
and counseling to prevent STIs
GRP 12 219/220/221 A H4523 22 ME HMO SCH COPAY (Y2013)
Aetna Medicaresni Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
We cover seYually transmitted infection (STI) screenings
for chlamydia, gonorrhea, syphilis, and Hepatitis B. These
screenings are covered for pregnant women and for certain
people who are at increased risk for an STI when the tests
are ordered by a primary care provider. We cover these tests
once every 12 months or at certain times during pregnancy.
We also cover up to two individual 20 to 30 mitiute,
to-face high-intensity behavioral counseling sessions
year for sexually active adults at increased risk for
We will only cover these counseling sessions
face-
each
STIs.
as a
preventive service if they are pr•ovided by a primaiy care
provider and take place in a primary care setting, such as a
doctor's office.
Services to treat kidney disease and conditions*
Covered services include:
• Kidney disease education services to teach kidney
care and help members make informed decisions
about their care. For members with stage IV chronic
kidney disease when r•eferred by their doctor, we
cover up to six sessions of kidney disease education
services per lifetime.
• Outpatient dialysis treatments (including dialysis
treatments when temporarily out ofthe service area,
as explained in Chapter 3)
• Inpatient dialysis treatments (if you are admitted as
an inpatient to a hospital for special care)
• Self-dialysis training (includes training for you and
anyone helping you with your home dialysis
treatments)
• Home dialysis equipment and supplies
• Certain home support services (such as, when
necessary, visits by traitled dialysis workers to
check on your home dialysis, to help in
etnergencies, and check your dialysis equiprnent and
water supply)
$0 for kidney disease
education seivices received
from your PCP
$0 fot• kidney disease
education setvices received
from other providers
$0 for in- and out-of area
outpatient dialysis
Inpatient dialysis — refer to
inpatient hospital care at the
beginning of this benefits
chart
$0 for home dialysis
equipment and suppiies
$0 per visit for Medicare-
covered home support
GRP_12 219/220/221 A H4523 23 ME HMO SCH COPAY (Y2013)
Aetna Medicares�i Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
services
Cei�tain drugs for dialysis are covered under yout• Medicare
Part B dtug benefit. For information about coverage for Part
B Drugs, please go to the section below, "Medicare Part B
prescription drugs."
*Prior authorization rules apply for certain services; contact
Member Services for information.
Skilled nursing facility (SNF) care*
(For a definition of "skilled nursing facility care,"
Chapter 10 of this booklet. Skilled nursing facilities
sometimes called "SNFs.")
see
at�e
100 days covered fot• each benefit period. Covered services
include but are not limited to:
• Semiprivate room (or a private room if inedically
necessary)
• Meals, including special diets
• Skilled nursing services
• Physical therapy, occupational therapy, and speech
therapy
• Drugs administered to you as part of your plan of
care (This includes substances that are naturally
present in the body, such as blood clotting factors.)
• Blood - including storage and administration.
Coverage of whole blood and packed red cells
begins only with the fourth pint of blood that you
need - you must eithet• pay the costs for the first 3
pints of blood you get in a calendar year� or have the
blood donated by you or someone else. All other
components of blood are covered beginning with the
first pint used.
• Medical and surgical supplies ordinarily provided
by SNFs
• Laboratory tests ordinarily provided by SNFs
• X-rays and other radiology services ordinarily
provided by SNFs
$0 per day
GRP 12 219/220/221 A H4523 24 ME HMO SCH COPAY (Y2013)
Aetna MedicareSM Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
• Use of appliances such as wheelchau•s ordinarily
provided by SNFs
• Physician/Practitioner services
Generally, you will get your SNF cat•e from network
facilities. However, under certain conditions listed below,
you may be able to pay in-network cost sharing for a
facility that isn't a network provider, if the facility accepts
our plan's amounts foi• payment.
• A nursing home or continuing care retirement
comtnunity where you wer•e living right before you
went to the hospital (as long as it pt•ovides skilled
nursing facility care).
A SNF where your spouse is living at the time you
leave the hospital.
*Pt•iot� authorization rules apply.
If you haven't been diagnosed
Smoking and tobacco use cessation (counseling to with an illness caused ot•
stop smoking or tobacco use) complicated by tobacco use:
$0 copay
If vou use tobacco, but do not ha�e signs or svmptoms of
tobacco-related disease: We cover two counseling quit
attempts within a 12-month period as a preventive service
with no cost to you. Each counseling attempt includes up to
four face-to-face visits.
If you use tobacco and have been dia�nosed with a tobacco-
related disease or are takin� medicine that mav be affected
by tobacco: We cover cessatioii counseling services. We
cover two counseling quit attempts within a 12-month
per�iod. Each counseling attempt includes up to fout• face-to-
face visits.
If you have been diagnosed
with an illness caused or
complicated by tobacco use, or
you take a medicine that is
affected by tobacco: $0 copay
Urgently needed care
Urgently needed care is care provided to treat a non- $0 copay for each Medicare-
emergency, unforeseen medical illness, injuiy, or condition covered urgently needed care
GRP_12 219/220/221 A H4523 25 ME HMO SCH COPAY (Y2013)
Aetna Medicaresnf Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
Services that are covered for you What you must pay (after
deductible) when you get these'
services
that requires immediate medical car•e. Urgently needed care
may be furnished by in-network providers or by out-of-
network providers when network providers are temporarily
unavailable ot� inaccessible.
This coverage is available world-wide.
� Vision care
Covered set•vices include:
• Outpatient physician services
treatment of diseases and
including treatment for
degeneration. Original Mec
for the diagnosis and
injuries of the eye,
age-related macular
icare doesn't cover
routine eye exams (eye refi�actions) for
eyeglasses/contacts.
• For people who are at high risk of glaucoma, such as
people with a family history of glaucoma, people
with diabetes, and Afi•ican-Americans who at�e age
50 and older: glaucoma screening once every 12
months.
• One pair of eyeglasses or contact lenses a$er each
cataract surgery that includes insertion of an
�
intraocular lens. (If you have two separate cataract
operations, you cannot reserve the benefit after the
first surgely and purchase two eyeglasses after the
second surgeiy.) Corrective lenses/fi•ames (and
replacements) needed after a cataract removal
without a lens implant. (Coverage is at the Medicare
Allowabie rate. Contact your eye pr�ofessional for
assistance.)
Our plan covers one routine eye exam every 12
months.
Prescription lenses and frames: Eyewear reirnbursement,
excluding eyeglasses or contact lenses after cataract sut�gery
(this amount does not count toward the maximum out-of-
pocket amount)
visit
$0 copay for exams to
diagnose and treat diseases and
conditions of the eye
$0 copay for one glaucoma
sct�eening every 12 months
$0 copay for one pair of
eyeglasses or contact lenses
after each catar•act surgery
$0 copay for one routine eye
exam evety 12 nlonths
Eyewear reimbursement:
$200 reimbursement eveiy 24
months
GRP 12 219/220/221 A H4523 26 ME HMO SCH COPAY (Y2013)
Aetna MedicareSM Plan (HMO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
Services that are covered for you What you must' pay (after
deductible) when you get these
seivices
� � ' �
The plan covers the one-time "Welcome to Medicare"
preventive visit. The visit includes a review of your health,
as well as education and counseling about the preventive
services you need (including certain screenings and shots),
and referrals for� other care if needed.
Important: We cover the "Welcome to Medicare"
preventive visit only within the fitst 12 months you have
Medicare Part B. When you make your appointment, let
your doctor's office know you would like to schedule your
"Welcome to Medicare" pt•eventive visit.
There is no coinsurance,
copayment, or deductible for
the "Welcome to Medicare"
preventive visit
*Note: See Chapter 4, Section 2.1 of the Evidence of Coverage for information on prior
authorization rules.
GRP_12 219/220/221 A H4523 27 ME HMO SCH COPAY (Y2013)
Aetna Medicare Plan (HMO)
2013 Prescription Drug Benefits Chart (Schedule of Copayments/Coinsurance)
AETNA LIFE INSURANCE COMPANY
Contract Holder Name: City Of Fort Worth
Contract Holder Group Agreement Effective Date: January 1, 2013
Contract Holder Number: 457106
This Prescription Drug Benefits Chat�t is part of the Evidence of Coverczge for our plan. When the
Evidence of Covef•age refers to the attachment for details of Medicar•e prescription drug benefits
covered undez� our plan, it is referring to this Presct•iption Drug Benefits Chart (Schedule of
Copayments/Coinsurance). (See the chapters titled, "Using the plan's cover�age for your Part D
prescription drugs" and "What you pay for your Part D prescription drugs.")
Annual deductible amount per member
�
Formulary Type: Managed Standard
Formulary
Initial
Limit:
1
i,�1
True Out-of-Pocket Amount:
GRP_12_227_F
$4,750
H4523 ME RX SCH COPAY (Y2013)
Aetna Medicare Plan (�IMO)
2013 Prescription Drug Benefits Chart (Schedule of Copayments/Coinsurance)
Initial Coverage Stage: Amount you pay, up to $2,970 in total covered prescription drug
eYpenses:
� 3 Tier Plan Network retail Network retail Preferred Out-of-
� pharmac� or non- mail order networlc �
(up to a 31-day preferred mail pharmacy pharmacy*
� supply) order pharmacy (up to a 90-day (up to a 31-day
(up to a 90-day supply) supply)
� supply)
��������.����..�� ��. .��,4-�.�_���� �.a;��m����.���_�-����,�� �����_ �� �������T
Tier 1 � � $10 $30 � � $20 �� �� $10 �� �
� Generic Drugs
��,�.� � ._, � � ��ti,.. �._ �.�v__���.���� -� ��� , w��_� �._.��� __� �_ �_r � �,.t .� �. w._ __� �_r_ .v� ,��
Tier 2 $20 $60 $40 $20
Preferred Brand
Drugs �
��� t �.�..,�.���� ���� � e _,_.�_,,_�..�u � - � ..� �
Tier 3 $60 � $180 �� $120 � � � $60
. Non-Preferred
Brand Drugs
�_�� � ., �u� � ��� �.�_r� �c��, _ �. �� ��_ _ � a � � ��� u �fi � �. � �
�_�_ �.. . _ � ��,,. . � . ��_, ��_� � _ �_ � _ _ . __ ��
*Coverage is limited to certain situations; see the Evidence of Coverage chapter titled "Using the
plan's coverage for• your Part D prescription drugs," Section 2.5.
Coverage Gap Stage: Amount you pay after you reach $2,970 in total covered prescription drug
expenses, and until you reach $4,750 in out-of-pocket covered pt•escription drug costs.
� 3 Tier Plan Networlc retail Network retail Preferred Out-of- �
pharmacy or non- mail order network
� (up to a 31-day preferred mail pharmacy pharmacy*
� supply) order pharmacy (up to a 90-day (up to a 31-day .
(up to a 90-day supply) supply)
�� w� � � � � � _ _ n � �� � ��. � ti . . �
� o � . , ti ��. � SuPP1Y)
�� � � ._� s _. ��
� ��P .. _ . ,. _ _ _
Tier 1 $10 $30 $20 $10
� Generic Drugs �
�. . _.-.� �w.v�_w � .�.... -, _�� �n �� _ �.� . w.._.. . _ . . .. �,, : >.. > � �_... � � _ ..
Tier 2 � LLv $20 $60 $40 $20 -�
Preferred
Br•and Dr•ugs
�„ �_� T,.4 ._�. �. ,. , n- �
GRP_12 227 F 2 H4523 ME RX SCH COPAY (Y2013)
Aetna Medicare Plan (HMO)
2013 Prescription Drug Benefits Chart (Schedule of Copayments/Coinsurance)
3 Tier Plan
Tier 3
Non-Preferred
Brand Drugs
',�I
Network retail
or non-
preferred mail
order pharmacy
(up to a 90-day
. .�
Preferred
mail order
pharmacy
(up to a 90-day
supply)
$120
Out-of-
network
pharmacyX
(up to a 31-day
supply)
G, � 1
*Coverage is limited to ceY•tain situations; see the Evidence of Coverage chapter titled "Using the
plan's coverage for your Pat•t D prescription drugs," Section 2.5.
If your plan does not include gap coverage for generic drugs, you pay 79% of the cost for generic
drugs and the plan pays the rest. If your plan does include supplemental coverage for generic
drugs, you will pay the applicable plan copay for the cost sharing tier, as shown in the chart
above.
If your plan does not include gap coverage for brand drugs, you pay 47.5% of the total cost (plus
a portion of the dispensing fee and vaccine administration fee, if any) for brand name drugs. If
your plan sponsor/former employer provides additional coverage during the Covet•age Gap phase
for covered brand-name drugs, you will generally continue to pay the same amount for covered
brand-name dr•ugs throughout the Coverage Gap phase of the plan as you paid in the Initial
Coverage phase.
Coinsurance-based cost sharing is applied against the overall cost of the drug, prior to the
application of any discounts or benefits.
Catastrophic Coverage Stage: Amount you pay for covered prescription drugs after reaching
$4,750 in out-of-pocket prescription drug costs.
Prescription D
-.r_ ..,�,� �;:r� __,--_—
Pei piescription oi refill
All covered
You pay $0
�
This Plan uses a Managed Standard Formulary:
Your plan uses a Managed Standard formulary, which means that only drugs on Aetna's
preferred drug list will be covet•ed under your plan as long as the dt�ug is medically necessary and
the plan rules are followed. Non-preferred copayment levels may apply to some drugs on the
preferred dt•ug list. If it is medically necessaS•y for you to use a prescription dl•ug that is eligible
for coverage under the Medicare drug benefit, but is not on our formulary, you can contact Aetna
to request a coverage exception. Your doctor inust submit a statement supporting your exception
Network retail
pharmacy
(up to a 31-day
supply)
GRP 12 227 F 3 H4523 ME RX SCH COPAY (Y2013)
Aetna Medicare Plan (HMO)
2013 Prescription Drug Benefits Chart (Schedule of Copayments/Coinsurance)
t•equest. Review the Aetna MedicaNe 2013 Group Formula�y (List of Cover�ed DNugs) for mot•e
information.
GRP_12 227 F 4 H4523 ME RX SCH COPAY (Y2013)
City of Fort Worth, Texas
Mayor and Council Communication
COUNCIL ACTION: Approved on 9/11/2012
DATE:
LOG NAME:
Tuesday, September 11, 2012
14MEDICARE
REFERENCE NO.: C-25822
SUBJECT:
Authorize Execution of an Agreement with Aetna Life Insurance Company for Administration of Fully
Insured Medicare Advantage Plans in the Amount Up to $1,188,192.00 for the First Year (ALL COUNCIL
DISTRICTS)
RECOMMENDATION:
DISCUSSION:
FISCAL INFORMATION:
FUND CENTERS:
TO Fund/Account/Centers
FROM Fund/Account/Centers
FE85 534730 0148540
',;• •• 11
CERTIFICATION5:
Submitted for City Manager's Office b�
Qriginating Department Head:
Additional Information Contact:
Susan Alanis (8180)
Karen Marshall (7783)
Margaret Wise (8058)
ATTACHMENTS
l. 14Medicare MWBE.�df
2. funding verification.�df