If you like to tell us more about your gender identity, preferred pronouns, or something else, click on the "add gender information" link below. In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin. Call 888-238-6240 for preauthorization. This plan's health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. You should always ask your physician or hospital whether they have contacted us. hing for four (4)smoking cessation counseling sessions per quit attempt and two (2) quit attempts per year. It is an extra amount that you pay for your monthly Medicare Part D prescription drug plan premiums and your monthly Medicare Part B premiums. Court ordered services, or those required by court order as a condition of parole or probation, except when medically necessary. You must show it whenever you receive services from a Network provider or fill a prescription at a Network pharmacy. d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms. Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate,in the lowest-cost nationwide plan option as determined by OPM. January 1 through December 31 of the same year. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the illness, injury or disease. Fraud or intentional misrepresentation of material fact is prohibited under the Plan. 120 days after we asked for additional information. You should also see section Important Notice About Surprise Billing Know Your Rights below that describes your protections against surprise billing under the No Surprises Act. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plans network and/or service area (if you use our Plan providers). Catastrophic protection for your Aetna Advantage Plan. You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Workers' Compensation Programs if you are receiving Workers' Compensation benefits. Box 550, Blue Bell, PA 19422-0550. "The holding will call into question many other regulations that protect consumers with respect to credit cards, bank accounts, mortgage loans, debt collection, credit reports, and identity theft," tweeted Chris Peterson, a former enforcement attorney at the CFPB who is now a law professor e)Include your email address, if you would like to receiveour decision via email. Please note that by providing us your email address, you may receiveour decision more quickly. We will reduce the Part B premium that you pay to the Social Security Administration by $75per month. If you choose to access preventive care from a non-network provider, you will not qualify for 100% preventive care coverage. Surgical benefits, not maternity benefits, apply to circumcision. If you enroll in a Medicare Advantage plan, tell us. We refer to these providers as Network Providers". It may take a few months to see these reductions credited to either your Social Security check or premium statement, but you will be reimbursed for any credits you did not receive during this waiting period. You can change your preferences at any time by returning to this site or visit our. The member has a current diagnosis that will most likely cause death within one (1) year or less despite therapy with currently accepted treatment; or the member has a diagnosis of cancer; AND. Keep a separate record of the medical expenses of each covered family member. Often these drugs require special handling, storage and shipping. The benefits in this brochure are effective January 1. You get access to local and national discounts on brands you know. Save on a wide variety of popular products from health and fitness vendors, like blood pressure monitors, pedometers and activity trackers, devices for pain relief and many other Omron products. If we determine that the recommended services and supplies are not covered benefits, you will be notified. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. Please refer toabove, Specialty Drugs for more information orvisit: www.aetnafeds.com/pharmacy.php. Box 14079 Lexington, KY 40512-4079. You are a family member no longer eligible for coverage. The Plan pays 100% for the medicalpreventive care services listed in this Section as long as you use a network provider. This information will be kept private with the rest of your medical record. The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. You are still responsible for your copayment, deductible or coinsurance based on the amount left after Medicare payment. This is the case even when the court has ordered your former spouse to provide health coverage for you. c) Ask you or your provider for more information. Provider networks may be more extensive in some areas than others. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies). Enjoy healthy food options like meal delivery to your home on your schedule. We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled. Other uncategorized cookies are those that are being analyzed and have not been classified into a category as yet. If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB Plan. Savings options on hearing aids and exams. If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until: These provisions apply only to the benefits of the hospitalized person. Ask your doctor, Who will manage my care when I am in the hospital?, "How can I expect to feel during recovery?". Any plan or program which is required by law. For precertification or criteria subject to medical necessity, please contact us at 888-238-6240. We determine our allowance as follows: The amount of an out-of-network provider's charge that is eligible for coverage. Thirty-seven preschools (16 government and 21 private) and 37 preschool teachers from Addis Ababa participated in this study.Data were collected using the Global Guidelines Assessment (GGA) SeeSection 1.Underwritten and administered by: Aetna Life Insurance Company. A generic equivalent may be dispensed if it is available, and where allowed by law. The experimental or investigational technology shows promise of being effective as demonstrated by the members participation in a clinical trial satisfying ALL of the following criteria: a. Search the Arkansas State Directory to locate Arkansas State Government Employees and Agencies by name or phone number.State Police CDL Testing Center at 3720 Comet St, Newport, AR 72112. Under current rules, just over 2.7 million North Carolina residents were. Aetna Advantage Plan Benefits Overview, Non-FEHB Benefits Available to Plan Members, Section 6. These blood or marrow stem cell transplants covered only in a National Cancer Institute or National Institutes of Health approved clinical trialor a Plan-designated center of excellence. Children incapable of self-support Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Services provided at a Walk in clinic or CVS MinuteClinic, Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services, Inpatient diagnostic tests provided and billed by a hospital or other covered facility, Generic oral contraceptives on our formulary list, Generic injectable contraceptives on our formulary list - five (5) vials per calendar year, Generic emergency contraception, including over-the-counter (OTC) when filled with a prescription, Brand name injectable contraceptive drugs such. In addition, you may have to wait until the next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D. For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below. Protection against catastrophic costs (out-of-pocket maximum): In-network: Nothing after $7,500/Self Only enrollment, $15,000/Self Plus One enrollment,or $15,000/Self and Family enrollment per year. Here is how we figure out the Plan allowance/recognized charge. Know how to use your medication. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. coverage or assistance with enrolling in a conversion policy (a non-FEHB individual policy). See Section 5(c) for charges associated with a facility (i.e., hospital, surgical center, etc.). You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. Blood glucose control must be optimized, and psychological clearance may be necessary. If you change your condition type, you will need to reselect your location and time slot. *Approved clinical trial necessary for coverage. If you have not met this expense level in full, yourpriorplan will first apply your covered out-of-pocket expenses until the prior years catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Is Gender Dysphor. Procedures, services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest. Self Only coverage is onlyfor the enrollee. For covered services you receive in hospitals outside the United States and performed by physicians outside the United States, send a completed Claim Form and the itemized bills to the following address. In-network and Out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. When you see a Plan physician, that physician must obtain approval for certain services such as inpatient hospitalization and the following services. Each tier has a separate out-of-pocket cost. When you use our network providers, you will receive covered services at reduced costs. Aetna offers a meal benefit through our relationship with GA Foods. 100% CLEAN ELECTRIC GRID: SB 1020 by Senator John Laird (D-Santa Cruz) establishes a pathway toward the states clean energy future. Contact your employing office for further information. The concurrent review process assesses the necessity for continued stay, level of care, and quality of care for members receiving inpatient services. Under Traditional medical coverage, in-network benefits apply only when you use a network provider. In-network and out-of-network deductibles do not cross apply and will need to be met separately for traditional benefits to begin. (See Section 9. We will send you an identification (ID) card when you enroll. Aetna Medicare Advantage plan is subject to Medicare rules. Note: When a newborn requires definitive treatment during or after the mothers confinement, the newborn is considered a patient intheirown right. Sign up here. Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Florida, Most of Florida -Alachua, Baker, Bay, Bradford, Brevard, Broward,Calhoun, Charlotte, Citrus, Clay, Collier, Columbia, DeSoto,Dixie, Duval, Escambia, Flagler, Franklin, Gadsden, Gilchrist, Glades, Gulf, Hamilton, Hardee, Hendry, Hernando, Highlands, Hillsborough, Holmes, Indian River, Jackson, Jefferson, Lake,Lee, Leon, Levy,Liberty, Madison,Manatee, Marion, Martin, Miami-Dade, Monroe, Nassau, Okaloosa, Okeechobee, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Putnam, St. Lucie, Santa Rosa, Sarasota, Seminole, St. Johns, Sumter, Suwannee, Taylor, Union, Volusia, Wakulla, Walton and Washington counties. To learn more about Medicare Advantage plans, contact Medicare at 1-800-MEDICARE (800-633-4227), (TTY:877-486-2048) 24 hours a day/7 days a week or at www.medicare.gov. Out-of-network benefits apply when you do not use a network provider. Arkansas, Most of Arkansas -Arkansas, Baxter, Benton, Boone, Bradley, Carroll, Clark, Clay, Cleburne, Columbia, Conway, Craighead, Crawford, Crittenden, Cross, Dallas, Drew, Faulkner, Franklin, Fulton, Garland, Grant, Greene, Hot Spring, Independence, Jackson, Jefferson, Johnson, Lawrence, Lee, Lincoln, Logan, Lonoke, Madison, Marion, Miller, Mississippi, Monroe, Montgomery, Newton, Ouachita, Perry, Phillips, Poinsett, Polk, Pope, Prairie, Pulaski, Randolph, Saline, Scott, Sebastian, Sharp, St. Francis, Stone, Union, Van Buren, Washington, White, Woodruff and Yell counties. OPM will send you a final decision within 60 days. There are no other administrative appeals. For a detailed listing of specialty medicationsvisit, Drugs and medicines approved by the U.S. Food and Drug Administration for which a prescription is required by Federal law, except those listed as, Lancets, alcohol swabs, urine test strips/tablets, and blood glucose test strips, Disposable needles and syringes for the administration of covered medications, Prenatal vitamins (as covered under the Plans formulary), as Depo Provera- five (5) vials per calendar year. It also may exclude any backdated adjustments made by CMS. Plan features and availability may vary by service area. is ford extended warranty worth it reddit, This provision has resulted in increases in state, Please note that some processing of your personal data may not require your consent, but you have a right to object to such processing. Not covered: Elective or non-emergency care, Note: Members will receive a Teladoc welcome kit explaining the benefit. Idaho, Most of Idaho- Ada, Adams, Bannock, Bear Lake, Benewah, Bingham, Blaine, Boise, Bonner, Bonneville, Boundary, Camas, Canyon, Caribou, Cassia, Clark, Custer, Elmore, Franklin, Fremont, Gem, Gooding, Jefferson, Jerome, Kootenai, Latah, Lincoln, Madison,Minidoka, Nez Perce, Oneida, Owyhee, Payette, Shoshone, Teton, Twin Falls, Valley, and Washingtoncounties. High complexity CLIA reference laboratory currently servicing over 500+ locations, including 7 Hospitals and 100+ Nursing Homes. However, we will cover the cost of treatment that exceeds the amount of the payment you received. This is what you will pay out-of-pocket for covered care: **Discounts do not apply to visits/claims submitted to your health insurance plan. If you have received benefits or benefit payments as a result of an injury or illness and you or your representatives, heirs, administrators, successors, or assignees receive payment from any party that may be liable, a third party's insurance policies, your own insurance policies, or a workers' compensation program or policy, you must reimburse us out of that payment. You can enroll in our Medicare Advantage plan with no additional premium. Online customer service that allows you to request member ID cards, send secure messages to Member Services, and more. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker. Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible. Contact your employing or retirement office if you are changing from Selfto Self Plus One or Self and Family or to add a newborn if you currently have a Self Only plan. The services listed below are for the charges billed by a physician or other health care professional for your surgical care. In-network: $49 until the deductible is met, 30% of the $49consult fee thereafter. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. District of Columbia All of Washington, DC. If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan. Emergency Services/Accidents, Section 5(e). Illinois, Most of Illinois- Adams, Alexander, Bond, Boone, Brown, Bureau, Calhoun,Carroll, Cass, Champaign, Christian, Clark, Clay, Clinton, Coles, Cook, Crawford, Cumberland, De Kalb, Dewitt, Douglas, DuPage, Edgar, Edwards, Effingham, Fayette, Ford, Franklin, Fulton, Gallatin, Greene, Grundy, Hamilton, Hancock, Hardin, Henderson, Henry, Iroquois, Jackson, Jasper, Jefferson, Jersey, Jo Daviess, Johnson, Kane, Kankakee, Kendall, Knox, La Salle, Lake, Lawrence, Lee, Livingston, Logan, Macon, Macoupin, Madison, Marion, Marshall, Mason, Massac, McDonough, McLean, McHenry, Menard, Mercer, Monroe, Montgomery, Morgan, Moultrie, Ogle, Peoria, Perry, Piatt, Pike, Pope, Pulaski,Putnam, Randolph,Richland, Rock Island, St. Clair, Saline, Sangamon, Schuyler, Scott, Shelby, Stark, Stephenson, Tazewell, Union, Vermilion, Wabash,Warren, Washington, Wayne, White, Whiteside, Will, Williamson, Winnebago and Woodford counties. If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. Ask us in writing to reconsider our initial decision. We coordinate specialized treatment needed by members with certain rare or complicated conditions and assist members who are admitted to a hospital for emergency medical care when they are traveling temporarily outside of the United States. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members. Inpatient services provided and billed by a hospital or other covered facility including an overnight residential treatment facility. Routine physicals - one (1) exam every calendar year, Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). Medicare Advantage (Part C)for additional details.). Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected. We will make our decision on the claim within 48 hours (1) of the time we received the additional information or (2) theend of the time frame, whichever is earlier. Make Offer. Your email address, if you would like to receive OPM's decision via email. Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure. Annuitants coverage and premiums begin on January 1. Refer to Other services in Section 3 for prior authorization procedures. Discover the services we offer and conditions we treat at Luminis Health. (See Section 5(a)). Trythese natural products andservices* at a discount. You can get care from any licensed provider or licensed facility. Note: Items not consideredroutine include (but not limited to): Note: Here are some things to keep in mind: Note: When a newborn requires definitive treatment during or after the mother's confinement, the newborn is considered a patient in theirown right. You mayappeal to the U.S. Office of Personnel Management (OPM) if we do not follow the requiredclaims process. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll. Washington, Most of Washington Adams, Asotin, Benton, Chelan, Clallam, Clark, Columbia, Cowlitz, Douglas, Ferry, Franklin, Garfield, Grant, Grays Harbor, Island, Jefferson, King, Kitsap, Kittitas, Klickitat, Lewis, Lincoln, Mason, Okanogan, Pacific, Pend Oreille, Pierce, San Juan, Skagit, Skamania, Snohomish, Spokane, Stevens, Thurston, Wahkiakum, Walla Walla, Whatcom, Whitman and Yakima counties. Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. Plus, national chains like LensCrafters, Trythese natural products andservices* at a discount. Those medical groups are:. You can view the complete list of these rights and responsibilities by visiting our website, If you want more information about us, call 888-238-6240 or write to Aetna at P.O. Click onyour Aetna Member website from. If the primary plan does not use a preferred provider arrangement, we use the lesser of Aetna's R&C and billed charges. Mental health and substance use disorder treatment: Out-of-network:50% of our Plan allowance and any difference between our allowance and the billed amount. Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from a state that recognizes common-law marriages)and children as described below. Nothing up to our Plan allowance for OTC drugs and prescription drugs approved by the FDA to treat nicotinede. Because they are out of our network, we pay for out-of-network services based on an out-of-network Plan allowance. We do not cover the dental procedure. Also, savings on LASIK laser eye surgery and replacement contact lenses delivered to your door. Any type of care provided according to Medicare guidelines, including room and board, that a) does not require the skills of technical or professional personnel; b) is not furnished by or under the supervision of such personnel or does not otherwise meet the requirements of post-hospital Skilled Nursing Facility care; or c) is a level such that you have reached the maximum level of physical or mental function and such person is not likely to make further significant improvement. Your care must continue to be authorized or precertified as required. We are here to help you navigate the financial obligations. Your Providermust file on the form CMS-1500, Health Insurance Claim Form. We will provide medical review criteria for denials to enrollees, members or providers upon request or as otherwise required. How much we pay and you pay depends on whether you use a network or non-network provider or facility. Certain drugs require your doctor to get precertification from the Plan before they can be covered under the Plan. The deductible is: In-network - $2,000 for Self Only enrollment, $4,000 for Self Plus One enrollment and Self and Family enrollment or Out-of-Network - $5,000 per Self Only, $10,000 for Self Plus One enrollment and Self and Family enrollment. Breastfeeding support, supplies and counseling for each birth, Intravenous ** Note: Requires Precertification. West Virginia, Most of West Virginia Barbour, Berkeley, Boone, Braxton, Brooke, Cabell, Calhoun, Clay, Doddridge, Fayette, Gilmer, Grant, Greenbrier, Hampshire, Hancock, Hardy, Harrison, Jackson, Jefferson, Kanawha, Lewis, Lincoln, Logan, Marion, Marshall, Mason, McDowell, Mercer, Mineral, Mingo, Monongalia, Monroe, Morgan, Nicholas, Ohio, Pendleton, Pleasants, Pocahontas, Preston, Putnam, Raleigh, Randolph, Ritchie, Roane, Summers, Taylor, Tyler, Tucker, Upshur, Wayne, Webster, Wetzel, Wirt, Wood and Wyoming counties. enrollees name and Plan identification number; patients name, birth date, identification number and phone number; reason for hospitalization, proposed treatment, or surgery; name and phone number of admitting physician; number of days requested for hospital stay. Get the results of any test or procedure.
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