|
Covered Expenses
|
|
Covered Expenses
Q. What types of medical services are covered by the Plan?
A. The Plan covers a wide range of medically necessary
health care services,
tests, treatments and supplies. Expenses must be approved by Medicare, must be a
covered expense under the Plan (listed below), and are subject to certain
Plan limitations.
In addition, the Plan may pay benefits for the following covered expenses that
are not eligible for reimbursement under Medicare Parts A and B:
outpatient prescription drugs
(so long as the person is not enrolled in Medicare Part D or a Medicare
Part C plan that provides a Medicare prescription drug benefit) and care
received while traveling outside the U.S.
The Plan may also pay limited additional benefits for covered expenses beyond reimbursements
by Medicare: in-home skilled-nursing care,
approved transition benefits and
skilled-nursing facilities.
Note: Although Medicare pays for an expense, the Plan may not provide benefits.
All covered expenses must be medically necessary as
defined by the Plan. See Key Terms.
Expenses covered by the Plan are:
- Acupuncture treatment performed by a physician.
- Chiropractic services of a doctor of chiropractic for the detection
and correction by manual or mechanical means of structural imbalance, distortion
or subluxation in the human body to remove nerve interference where such interference
is the result of or related to distortion, misalignment, or subluxation of or in the
vertebral column, and X-rays incidental thereto.
- Colonoscopies that are not for the purpose of routine screening, but are related to the diagnosis and treatment of an injury or illness.
- Emergency transportation provided by professional ambulance or air ambulance for the first trip to or
from the nearest hospital that can provide the necessary care for each illness or injury or non-emergency transportation if approved by Medicare.
- Home-health care, if approved by Medicare.
- Hospice care, if approved by Medicare.
- Hospital charges for a semiprivate room, meals and general-duty nursing
care (as opposed to the services of a private-duty
nurse).
- Laboratory tests, analyses or X-rays made for diagnostic or
treatment purposes.
- Outpatient prescription drugs unless you are enrolled in Medicare
Part D.
- Physical therapy prescribed in writing by a physician
and performed by a licensed physical therapist.
- Radiation therapy including X-ray, radon, radium and radioactive
isotope treatments.
- Routine pap smears and mammograms, if approved by Medicare.
- Prescription smoking deterrent medications.
- Prostate cancer screening, if approved by Medicare.
- Second surgical opinion, and third surgical opinion, if first
and second opinions contradict.
- Skilled-nursing care —
in-home — prescribed in writing by a physician, essential to medical care and approved in advance by Aetna.
- Skilled-nursing services and skilled-rehabilitation services provided in a
skilled-nursing facility,
if approved by Medicare. When your stay in a skilled-nursing facility is covered by
Medicare, the Plan helps pay for your care during Medicare's 100 days of coverage. If you need
skilled-nursing care for more than 100 days, the Plan will continue to help pay for your care
for as long as all of the following conditions are met:
- You are confined to the Medicare-approved skilled-nursing facility primarily because
you need skilled care.
- Your condition requires daily skilled-nursing or skilled-rehabilitation services which, as a practical matter,
can only be provided in a skilled-nursing facility.
- Your need for skilled care continues for a consecutive number of days without interruption beyond Medicare's 100 days.
- A physician certifies that you need, and you receive, skilled-nursing or skilled-rehabilitation services on a daily basis.
- The care rendered in the Medicare-approved skilled-nursing facility is primarily non-custodial care as determined by Aetna reasonably applying Medicare standards.
- Surgery or other medical care and treatment by physicians.
- Treatment of fractures and dislocations of the jaw and for certain cutting procedures in
the mouth (other than care of the teeth and gums for extractions and repairs).
- Treatment of temporomandibular joint (TMJ) dysfunction, if approved by Medicare.
- Vaccinations for flu and pneumonia, if approved by Medicare and billed by your physician. Shingles vaccinations are covered if administered by a physician, whether the vaccine is provided by the physician or obtained through the prescription drug program.
Remember, you must need skilled-nursing care on a daily basis.
Neither Medicare nor the Plan will cover your stay if you need skilled-nursing care
only occasionally, such as once or twice a week.
|
Equipment and Supplies
- Appliances to replace lost physical organs or body parts or to help them function if impaired.
- Bandages and surgical dressings.
- Blood (if not replaced) or other fluids injected into the circulatory system.
- Drugs and medications available only with a physician's
written prescription and not otherwise excluded, and which are
approved by the U.S. Food and Drug Administration for the specific
diagnosis.
- Durable medical equipment rental for temporary therapeutic use such as:
- Hospital-type beds;
- Rental of a mechanical ventilator or other mechanical equipment for treating respiratory paralysis;
- Oxygen and the equipment to administer it; and
- Wheelchairs.
The Plan may approve the purchase of these items, if the net cost would be lower than renting.
- Lenses — either first pair of contact lenses, or eyeglass lenses, or intraocular lenses — if required
in conjunction with cataract surgery.
- A wig or hairpiece (synthetic, human hair or blends) ordered by
a physician for hair loss due to injury, disease, or treatment of
a disease, or ordered in connection with chemotherapy treatment.
|
