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Covered expenses

Covered expenses for the Retiree Medical Plan - POS II 'A' and POS II 'B' Options

Q. What types of medical services are covered by the Plan? 

A. The Plan covers a wide range of health care services, tests, treatments, and supplies. For plan purposes, all covered expenses must be medically necessary and not excluded. Generally Aetna's Clinical Policy Bulletins (CPBs) are relied upon to ensure consistent determination of coverage under the Medical Plan. Aetna's CPB's may be viewed online at www.aetna.com.

Covered expenses (POS II A and B)

Some of the services covered by the Plan are listed below. Services not listed as a covered expense are excluded.  If you do not see your procedure or treatment listed below, please contact Aetna Member Services listed in the Information sources section of this SPD to confirm coverage for the expense.

  • Acupuncture if performed by a physician.
  • Ambulatory surgical center, care, or services. An ambulatory surgical center:
  • Is established, equipped and operated in accordance with applicable local laws primarily for the purpose of performing surgical procedures,
  • Is operated under the full-time supervision of a licensed doctor of medicine or doctor of osteopathy,
  • Permits a surgical procedure to be performed only by a duly qualified physician who, at the time the procedure is performed, has admitting privileges in at least one hospital to perform such a procedure,
  • Has at least two operating rooms and at least one post-anesthesia recovery room, is equipped to perform x-ray and laboratory examinations, and has available trained personnel and necessary equipment, including a defibrillator, a tracheotomy set, and a blood supply, to handle foreseeable emergencies,
  • Provides the full-time services of one or more registered graduate nurses for patient care in operating rooms and in the post-anesthesia recovery room,
  • Maintains a written agreement with at least one hospital in the area for immediate acceptance of patients who develop complications or require post-operative confinement, and
  • Maintains appropriate medical records for each patient.
  • Braces, crutches and prostheses required because of an injury or disease. Coverage is generally limited to the purchase price.
  • Chiropractic services, performed by a licensed doctor of chiropractic who is acting within the scope of his or her license, up to $1,000 per person per year (benefits paid for acupuncture and supplies billed by a doctor of chiropractic are not included in the $1,000 annual maximum).
  • Dental work required by an accidental injury to sound, natural teeth or the mouth. Also, certain cutting procedures in the mouth. (See Dental treatment in Specific Coverage).
  • Diagnosis and treatment of the underlying medical cause of infertility, but Comprehensive Infertility Services, fertility prescriptions, and Advanced Reproductive Technologies (ART) are not covered.
  • Doctor visits at home, a hospital or an office, including emergency room care.
  • Drugs and medicines obtainable only with a physician's prescription and approved by the U.S. Food and Drug Administration for the specific diagnosis.
  • Durable medical equipment (DME) when medically necessary, prescribed by a physician for the treatment of an illness or injury. Some DME may require preauthorization from Aetna. For more information on precertification, see the National Precertification List on the Aetna member website. Replacement, repair and maintenance are only covered for purchased DME if:    
    • It cannot be repaired,                
    • Repairs would be more expensive than purchasing or renting replacement equipment, or                         
    • The attending physician recommends replacement because of a change in the patient’s physical condition.
  • Expert Medical Opinion services provided through the designated service provider (2ndMD), including evaluation of medical records and consultation either online or by phone to confirm diagnosis and recommend a treatment plan for complex healthcare needs. To register for services, call 866-410-8649 or www.2ndMD.com/Aetna.
  • Extended Care Facility when precertified. (See Extended-care facility in the Specific Coverage section.) 
  • Gender reassignment surgery consistent with Aetna's Clinical Policy Bulletins.
  • Hearing aids. (See Hearing aid in the Specific Coverage section for more details).
  • Home health aides to provide individualized, non-custodial home care.
  • Hospice care.
  • Hospital emergency room care, including surgical care and other related charges.
  • Hospital semi-private room and board, x-ray and pharmacy, tests and other medical supplies and services received in a hospital.
  • Immunizations/vaccinations obtained outside of a physician's office or hospital. Some immunizations can also be obtained or administered at participating retail pharmacies, using the Aetna ID card at an Aetna network pharmacy, or the Express Scripts ID card at an Express Scripts network pharmacy.
  • Inpatient services performed by surgeons, anesthesiologists, and other physicians.
  • Insulin and diabetic supplies received in a doctor's office or an outpatient setting are covered medical expenses. Insulin and diabetic supplies obtained in a retail setting, such as a pharmacy or those obtained by home delivery, are covered by Express Scripts, or are provided through the Livongo Pharmacy Diabetes Management program.
  • Morbid obesity (generally 100% or more over ideal body weight) treatments including physician expenses for the initial office visit and laboratory costs. Contact Aetna Member Services for guidelines regarding eligibility and approved programs for this coverage.
  • Network mental health and substance abuse treatment (both inpatient and outpatient) and non-network mental health and substance abuse treatment (both inpatient and outpatient).
  • Nutritional counseling performed by a licensed nutritionist for anorexia nervosa, bulimia nervosa and after bariatric surgery consistent with Aetna's internal Clinical Policy Bulletins.
  • Oral-motor therapy ordered by a physician for treatment of dysphagia or hypotonia.
  • Outpatient medical tests and surgery.
  • Physical therapy or occupational therapy for treatment of illness, injury or disease, which is performed by a licensed physical or occupational therapist who is acting within the scope of his or her license. If you or your provider anticipates that your current course of therapy may exceed 25 visits, have your physician or therapist submit medical records with each physical therapy claim. Claims for therapy services beyond the 25th visit are subject to medical review. Additional information will be required. Claims will not be paid if the service is found to not be medically necessary.
  • Prescription smoking deterrent medications.
  • Preventive care services. (See POS II Network in the Basic Plan Features section for details).
  • Private-duty nursing care rendered by a nurse when furnished outside of a hospital if such care requires a nurse's services and it is determined that such services are neither primarily custodial in nature nor could be provided by a person other than a nurse.
  • Professional emergency transportation services. The Plan pays for medically necessary trips to or from the nearest facility capable of handling the situation. In addition, the Plan pays for transportation to the nearest POS II network facility once the patient is stabilized in a non-network facility.
  • Reconstructive surgery including, but not limited to, surgery required because of a mastectomy. The Plan pays benefits for:
  • Reconstructive surgery of the breast on which the surgery was performed,
  • Reconstructive surgery of the other breast in order to produce symmetry, and
  • Prostheses for physical complications of mastectomy.
  • Services related to the pregnancy of a covered child, but not those related to the child born to the family member.
  • Medically necessary procedures to evaluate or diagnose learning, intellectual or developmental disability; excluding, Applied Behavioral Analysis and other training, educational, or behavioral modification for learning, intellectual or developmental disability.
  • Skilled-nursing care. (See Skilled-nursing care in Specific Coverage in the Covered Expenses section for details).
  • Speech therapy, on an outpatient basis, to:
  • Restore speech after a demonstrated previous ability to speak is lost or impaired,
  • Improve or develop speech after surgery to correct a birth defect which impaired or would have impaired the ability to speak, or
  • Improve or develop speech lost or impaired by an irreversible and permanent profound hearing loss resulting from a birth defect. (See Speech Therapy under Exclusions. Submission of a proposed treatment plan for a benefit predetermination is strongly recommended.)
  • Sterilization procedures.
  • Treatment of temporomandibular disorders, sometimes referred to as TMJ/TMD, including splints and orthotics, when preauthorized by Aetna. This includes diagnosis and surgical treatment of the jaw and cranio-mandibular joint resulting from an accident, trauma, congenital or developmental defect, or pathology.
  • Telemedicine services through the designated service provider (Teladoc) for non-emergency medical and behavioral health conditions such as cold/flu symptoms, stomach aches, common childhood illnesses, depression, stress, and anxiety.
  • Vision examinations and eyeglasses or contact lenses needed because of injury or disease.
  • Vision therapy by a physician for amblyopia and strabismus up to a maximum of 32 vision therapy visits or sessions.
  •  Abortion if the life of the mother is in danger or complications from pregnancy arise or other specific circumstances.
  • Habilitative therapy - Aetna standardly covers rehabilitation and habilitation services, as long as the services aren’t considered experimental and investigational and aren’t specifically excluded under a plan: 
                                     o Rehabilitation is defined as services to restore body function following an accident, injury or because of a medical condition  
                                     o Habilitation is defined as services that help a person keep, learn or improve skills for daily living—generally due to a behavioral or developmental deficit  

Specific coverage 

Dental treatment

Certain dental expenses are covered under the POS II A and B options. Covered services include the following when provided by a physician, dentist and hospital:

  • • Cutting out:
    - Cysts, tumors, or other diseased tissues
     
  • • Cutting into gums and tissues of the mouth. 
    ‒ Only when not associated with the removal, replacement or repair of teeth

 
Oral surgery and related procedures covered under the POS II options are reimbursed at 75% for the POS II 'A' and 80% for the POS II 'B', regardless of the provider’s network participation.

Extended-care facilities

An extended-care facility provides skilled-nursing services and rehabilitation care. Extended-care facility charges are covered expenses if these conditions are met:

Reimbursement is based on the facility charge or daily room and board rate of the hospital from which the patient transferred, whichever is less.

Skilled-nursing care

Skilled-nursing care is covered if medically necessary. Nursing care that helps a person meet personal needs and daily living activities, such as bathing, dressing, eating or administering oral medication, even if ordered by a physician and performed by a licensed medical professional, is considered custodial and is not a covered expense eligible for benefits. Also, charges for a private-duty nurse in a hospital or an extended-care facility are not covered.

Skilled care

Skilled care involves nursing or rehabilitation services that can be provided only by licensed medical professionals. For example, intravenous feeding is a skilled service.

Hearing aids

Benefits are provided up to a maximum of $2,500 after the deductible and coinsurance are paid for one or more hearing aids every rolling five year period, which also includes the repair of a hearing aid. However, shipping and handling charges and routine maintenance such as battery replacement are not covered. The amount allowed is subject to reasonable and customary limits but not negotiated rates. There are no POS II preferred providers for hearing aids and related materials. The member will be responsible for the difference between the billed and allowable amount regardless of provider participation.

You may be able to maximize your benefit through the Amplifon Hearing Health Care (formerly HearPo) or the Hearing Care Solutions Discount Program. These programs are available to Aetna participants and offer discounts on hearing exams, services and hearing aids. If you go to a participating hearing discount center, your out-of-pocket expenses could be lower. To find a participating hearing discount center location, visit www.aetna.com and select “Hearing Discount Locations”. To compare costs, please call Amplifon Hearing Health Care at 1-888-HEARING (1-888-432-7464) or Hearing Care Solutions at 1-866-344-7756 and identify yourself as an Aetna member.

Organ, tissue and bone marrow transplants

Aetna's National Medical Excellence® Program (NME Program) coordinates all aspects of organ, tissue, and bone marrow transplants and other complex specialized care. Providers in this program are recognized as centers of excellence with demonstrated improved outcomes in their area of expertise. In addition, if travel over 100 miles is required, transportation and lodging for the patient and a family member will be covered. The NME Program is separate and distinct from the Centers of Excellence described in the Health Management Programs section of this SPD.

The NME Program is available on a voluntary basis. Contact Aetna Member Services for information.

Case management alternative treatment program 

If as a result of a catastrophic or chronic illness, injury, mental health, or in conjunction with certain organ transplant procedures, a participant proposes an alternative course of treatment, the Administrator-Benefits may waive any exclusion or limitation under the Plan which would otherwise apply to covered medical expenses, the reimbursable portions of covered medical expenses or out-of-pocket limits if such waiver would result in overall cost savings to the Plan. The review will include factors such as the efficacy of the proposed treatment, the patient's condition, availability and efficacy of other treatments that are approved for the patient's diagnosis, and the prior use of appropriate treatments for the condition. Such approval must be prior to the participant commencing the alternative course of treatment.

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