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. Certain 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 recognized physician.
• Anesthesia
• Chiropractic services, performed by a licensed doctor of chiropractic who is acting within the scope of his or her license.
• 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. Remember, you must need skilled-nursing care on a daily basis. Neither Medicare nor the Plan will cover your expenses if you need skilled-nursing care only occasionally, such as once or twice a week.
• 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, pneumonia and preventive shots, if approved by Medicare and billed by your physician. Medically necessary shingles vaccine and its administration when received in a physician’s office or other medical clinic. Coverage for the shingles vaccination at a retail pharmacy may be covered under your pharmacy benefits plan.

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, illness, or treatment of an illness, or ordered in connection with chemotherapy treatment.