Additional integrated programs are available to you and your family members to help you manage your health and to assist you in obtaining good health care when care is needed. These programs reflect a commitment by you and the company to good health and quality care. The Health Management tools and resources available to Aetna Select participants include a 24-Hour Nurse Line, Medical and Behavioral Health Advocates, Condition Management Programs, Cancer Care Program, Expert Medical Opinion Services, and Centers of Excellence.
Health Management tools and resources are available to you at no additional cost. However, health care claims (e.g., doctor's fees or facilities charges) are processed according to the Plan's provisions.
24-Hour nurse line
Trained, licensed nurses are available by telephone at 1-800-556-1555, 24 hours a day, 7 days a week to answer routine questions about your health, or questions about a specific medical situation, condition or concern. However, these nurses cannot diagnose medical conditions, prescribe medication or give specific medical instruction. Topics discussed during your call may include services and expenses not covered under the Plan.
The nurse may refer you to a Health Advocate for a more detailed conversation if you face a health risk or serious medical condition.
Health Advocate Program
The Health Advocate Program provides direct support to you, your family, and your treating physician(s) in the management of specific health care needs. The Health Advocate staff consists of registered nurses, supported by a medical director. Once you begin working with a Health Advocate, the nurse will work personally with you as long as you need support.
Health Advocates will assist you to coordinate a wide array of health care-related support and educational services. As situations require, your Health Advocate will assist you with admission, counseling, inpatient advocacy, discharge planning and home counseling. The nurse will also act as your proactive partner, working directly with you to help you navigate the health care delivery system by assisting with the coordination and management of your health care needs and collaborating with others involved in your treatment. Your Health Advocate could refer you to a Condition Management nurse if you are identified as needing treatment for a condition that is included in the program.
If you or a family member is identified as having an illness or condition or if you have signs or symptoms that indicate that you are at risk for contracting a serious illness or condition and you have primary coverage under the Retiree Medical Plan, the Health Advocates may contact you to provide support, information, and guidance. In addition, you may contact Aetna Member Services to reach a Health Advocate if you have any questions.
Condition Management Program
If you have certain chronic illnesses and you meet certain eligibility criteria, you may be contacted by a licensed registered nurse through the Condition Management Program offered by Optum or you can contact Optum directly at 1-800-557-5519. These specifically trained nurses focus on helping participants with conditions in which education, daily choices, and lifestyle decisions can have a significant effect on health and the progression of the condition. If you elect to work with a condition management nurse, you will receive educational materials, assistance in managing your condition, and personal support.
Condition management programs available through Optum include congestive heart failure, coronary artery disease, diabetes, chronic obstructive pulmonary disease (COPD), and orthopedic health support programs.
Cancer Care Program
If you are newly diagnosed with cancer, undergoing active treatment for cancer or are experiencing a recurrence, you may be referred to a specifically trained Cancer Care nurse through your Health Advocate or Condition Management nurse. Referrals will be made to Optum for support to those undergoing treatment or you can call Optum directly at 1-800-557-5519.
Expert Medical Opinion Services
If you or a family member receive a diagnosis or treatment plan requiring complex medical care, you have access to expert medical opinion services through 2ndMD. Specialists who are recognized experts in their field will review medical records related to the diagnosis and provide an opinion on the recommended treatment, including a detailed report you can share with your physician or Health Advocate nurse. Expert opinion consults are available at no additional cost to you and can be accessed through a mobile application, web portal, or phone. Call 866-410-8649 or www.2ndMD.com/Aetna to initiate services.
Pharmacy Diabetes Management
Livongo and Express Scripts offer a diabetes remote monitoring and acute assistance program at no additional cost to you. Key benefits of the program include unlimited test strips and lancets, availability of a glucose meter with automatic uploads and secure access to readings at any time, as well as personalized real-time tips to manage diabetes effectively. Program participants will also have access to Certified Diabetes Educators who can answer nutrition or lifestyle questions. Call Livongo at 1-800-945-4355 to enroll or find out more information.
Centers of Excellence and Institutes of Excellence
Centers of Excellence (COE) and Institutes of Excellence (IOE) are nationally recognized facilities for the treatment of certain conditions or the delivery of certain procedures where high-level knowledge and expertise provide better care and more likely positive outcomes.
COEs/IOEs are not available for all diseases and all conditions or procedures relevant to a disease state. For instance, at this time there are COEs/IOEs for pancreatic cancer, but there is insufficient information available to select COEs/IOEs for lung cancer. Changes to identified COEs/IOEs may occur in the future. If you would like to learn more about different COE/IOE options you will need to contact the 24-hour nurse line and ask to be put in contact with a Health Advocate who will be able to discuss different options with you.
Participation in a COE/IOE program is voluntary, and designed to direct participants to nationally recognized facilities with more positive outcomes. A COE/IOE recommended treatment plan, however, must meet the Plan provisions for medically necessary care in order for claims to be eligible for reimbursement.
Whenever clinically appropriate, you will be referred to a local COE/IOE. If access to a clinically appropriate COE/IOE requires the patient to travel 100 or more miles, the Plan will reimburse reasonable transportation costs for you and a caregiver. The Plan will also provide a per diem for you and a caregiver to cover lodging and other expenses. If you become hospitalized, only your caregiver will receive the per diem, because food and lodging are already provided as part of the hospital charge. The per diem amounts are established by the Administrator-Benefits.
If you decide not to use a COE/IOE, you will not incur additional out-of-pocket costs for choosing another hospital in the Plan's network.