Directory. Delaware. Aetna Golden Medicare Plan Aetna Golden Choice Plan

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1 Directy Physicians, Hospitals and Other Health Care Professionals Aetna Golden Medicare Plan Aetna Golden Choice Plan Delaware M0001_7B_70509 (05/2007) DE

2 Please Call Us If You Have Questions F Member Assistance F assistance with questions regarding benefits, referrals, other infmation related to your health plan, please call us at the toll-free phone number that is located on your ID card. If you prefer to contact us by , please go to and log in to Aetna Navigat (our secure member website). Then, click on Contact Us and send us your question(s). An Aetna representative will respond to you within 24 hours. Interpreter Aetna can help explain benefit and provider infmation in up to 140 languages! If you require Spanish speaking assistance, please contact us at the toll free number located on your ID card and follow the prompts. If you require assistance in a language other than Spanish, please call us at the toll free number that is located on your ID card and ask f an interpreter. Hearing Impaired TDD: (hearing impaired only) Need To Find a Provider? Through the Aetna Navigat website located at members can easily link to our DocFind online provider directy to locate netwk physicians other health care professionals in your area. (DocFind is updated 3 times weekly and is available to our members 24 hours a day, 7 days a week). Online at F additional infmation about physicians hospital affiliations, medical education, board certification status and languages spoken. Please connect to the Aetna website f fast access to other health resources available to our members. F Sales Infmation Not yet an Aetna Medicare member and have questions about how to enroll? Please call an Aetna Sales Representative at (TTY/TDD ), Monday through Friday, 8:00 a.m. to 6:00 p.m. Imptant note: Many health care providers listed in this directy are accepting new patients. There may be others who are accepting existing patients only. Please contact the provider to confirm. We will attempt to provide to you updated infmation on the availability of the physicians, hospitals and other health care professionals listed in this directy. Providers are independent contracts and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care guarantee access to health services.

3 Table of Contents Imptant Disclosure Infmation...III Spanish Version...XXVII Netwk Hospitals and Skilled Nursing Facilities...2 Institutes of Excellence Transplant Facilities...6 Nationally Contracted Walk-In Clinics...18 Netwk Primary Care Physicians...36 Netwk Obstetricians and Gynecologists / Women s Health Specialists...62 Netwk Specialists...72 Netwk Behavial Health Providers Netwk Eye Care Providers Netwk Dental Providers Netwk Pharmacies Other Participating Netwk Providers Index of Netwk Providers Speaking Additional Languages Index of Netwk Providers Map of Service Area...See Back of Directy F up-to-date listings, visit our DocFind online provider directy at Contact Member either online at the toll-free number on your ID card with questions about selecting changing a provider PCP. You must be entitled to Medicare Part A and continue to pay your Part B premium and Part A, if applicable. Coverage is provided through a Medicare Advantage ganization with a Medicare contract and benefits, limitations, service areas and premiums are subject to change on January 1 of each year. F the Aetna Golden Medicare Plan: You must use netwk providers except f emergent care out of area urgent care/renal dialysis. F the Aetna Golden Choice Plan: Higher costs apply f out-of-netwk services. Precertification, pri approval of coverage f certain services is requested. Providers must be licensed and eligible to receive payment under the federal Medicare program. If you are a dual eligible individual (eligible f both Medicare and state Medicaid programs) and have enrolled in an Aetna Medicare Advantage plan, it is imptant that you present both your Aetna Medicare and state Medicaid ID cards when you receive plan services. Some providers do not accept state Medicaid patients and this could impact your out of pocket costs. I

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5 Imptant Disclosure Infmation Aetna Golden Medicare Plan, Aetna Golden Choice Plan Note: Medicare Advantage plan requirements govern and supersede any state general disclosures contained within. Plan of Benefits Covered services include most types of treatment provided by primary care physicians, specialists and hospitals. However, the health plan does exclude and/ include limits on coverage f some services, including but not limited to, cosmetic surgery and experimental procedures. In addition, in der to be covered, all services, including the location (type of facility), duration and costs of services, must be medically necessary as defined below and as determined by Aetna*. The infmation that follows provides general infmation regarding Aetna health plans. F a complete description of the benefits available to you, including procedures, exclusions and limitations, refer to your specific plan documents, which may include the Schedule of Benefits, Certificate of Coverage, Group Agreement, Group Insurance Certificate, Group Insurance Policy and any applicable riders and amendments to your plan. Direct Access Ob/Gyn Program This program allows female members to visit any participating obstetrician gynecologist f a routine well woman exam, including a Pap smear, and f obstetric gynecologic problems. Obstetricians and gynecologists may also refer a woman directly to other participating providers f covered obstetric gynecologic services. All health plan preauthization and codination requirements continue to apply. If your Ob/Gyn is part of an Independent Practice Association (IPA), a Physician Medical Group (PMG), an Integrated Delivery System (IDS) a similar ganization, your care must be codinated through the IPA, the PMG similar ganization and the ganization may have different referral policies. Health Care Provider Netwk All hospitals may not be considered participating f all services. Your physician can contact Aetna to identify a participating facility f your specific needs. Certain PCPs are affiliated with integrated delivery systems, independent practice associations ("IPAs") other provider groups, if you select these PCPs you will generally be referred to specialists and hospitals within that system, association group ( ganization ). However, if your medical needs extend beyond the scope of the affiliated providers, you may request coverage f services provided by nonganization affiliated netwk physicians and facilities. In der to be covered, services provided by non-ganization affiliated netwk providers may require pri authization from Aetna and/ the integrated delivery systems other provider groups. You should note that other health care providers (e.g. specialists) may be affiliated with other providers through ganizations. These ganizations, their affiliated providers may be compensated by Aetna through a capitation arrangement other global payment method. The ganization then pays the treating provider directly through various methods. You should ask your provider how he she is being compensated f providing health care services to you and if he/she has any financial incentive to control costs. Advance Directives An advance directive is a legal document that states your wishes f medical care. It can help docts and family members determine your medical treatment if, f some reason, you can t make decisions about it yourself. There are three types of advance directives: Living will spells out the type and extent of care you want to receive. * Aetna is the brand name used f products and services provided by one me of the Aetna group of subsidiary companies. III

6 Durable power of attney appoints someone you trust to make medical decisions f you. Do-not-resuscitate der states that you don t want to be given CPR if your heart stops if you stop breathing. You can create an advance directive in several ways: Get an advance medical directive fm from a health care professional. Certain laws require health care facilities that receive Medicare and Medicaid funds to ask all patients at the time they are admitted if they have an advance directive. You don t need an advance directive to receive care. But we are required by law to give you the chance to create one. Ask f an advance directive fm at state local offices on aging, bar associations, legal service programs, your local health department. Wk with a lawyer to write an advance directive. Create an advance directive using computer software designed f this purpose. If you have Medicare coverage and aren t satisfied with the way Aetna handles advance medical directives, you can file a complaint with your Medicare State Survey and Certification Agency. Visit f infmation on specific state agencies. Or call the Medicare phone number at MEDICARE ( ). F the hearing and speech impaired, dial TTY Advanced Directives and Do Not Resuscitate Orders. American Academy of Family Physicians, March (Available at Transplants and Other Complex Conditions Our National Medical Excellence Program and other specialty programs helps you access covered treatment f transplants and certain other complex medical conditions at participating facilities experienced in perfming these services. Depending on the terms of your plan of benefits, you may be limited to only those facilities participating in these programs when needing a transplant other complex condition covered. Note: There are exceptions depending on state and federal Medicare requirements. Prescription Drugs If your plan covers outpatient prescription drugs, your plan may include a preferred drug list (also known as a "drug fmulary"). The preferred drug list includes a list of prescription drugs that, depending on your prescription drug benefits plan, are covered on a preferred basis. Many drugs, including many of those listed on the preferred drug list, are subject to rebate arrangements between Aetna and the manufacturer of the drugs. Such rebates are not reflected in and do not reduce the amount you pay to your pharmacy f a prescription drug. In addition, in circumstances where your prescription plan utilizes copayments coinsurance calculated on a percentage basis a deductible, your costs may be higher f a preferred drug than they would be f a nonpreferred drug. F infmation regarding how medications are reviewed and selected f the preferred drug list, please refer to Aetna's website at the Aetna Medicare Preferred Drug (Fmulary) Guide. Printed Aetna Medicare Preferred Drug Guide infmation will be provided, upon request if applicable, annually f current members and upon enrollment f new members. Additional infmation can be obtained by calling Member at the toll-free number listed on your ID card. The medications listed on the preferred drug list are subject to change in accdance with applicable state law. Your prescription drug benefit is generally not limited to drugs listed on the preferred drug list. Medications that are not listed on the preferred drug list (nonpreferred nonfmulary drugs) may be covered subject to the limits and exclusions set fth in your plan documents. Covered nonfmulary prescription drugs may be subject to higher copayments coinsurance under some benefit plans. Some prescription drug benefit plans may exclude from coverage certain nonfmulary drugs that are not listed on the preferred drug list. If it is medically necessary f you to use such drugs, your physician ( pharmacist in the case of antibiotics and analgesics) may contact Aetna to request coverage as a medical exception. Check your plan documents f details. IV

7 In addition, certain drugs may require precertification step-therapy befe they will be covered under some prescription drug benefit plans. Step-therapy is a different fm of precertification which requires a trial of one me "prerequisite therapy" medications befe a "step therapy" medication will be covered. If it is medically necessary f you to use a medication subject to these requirements, your physician can request coverage of such drug as a medical exception. In addition, some benefit plans include a mandaty generic drug cost-sharing requirement. In these plans, you may be required to pay the difference in cost between a covered brand name drug and its generic equivalent in addition to your copayment if you obtain the brand-name drug. Nonprescription drugs and drugs in the Limitations and Exclusions section of the plan documents (received and/ available upon enrollment) are not covered, and medical exceptions are not available f them. Depending on the plan selected, new prescription drugs not yet reviewed f possible addition to the preferred drug list are either available at the highest copay under plans with an "open" fmulary, excluded from coverage unless a medical exception is obtained under plans that use a "closed" fmulary. These new drugs may also be subject to precertification step-therapy. You should consult with your treating physician(s) regarding questions about specific medications. Refer to your plan documents contact Member f infmation regarding terms, conditions and limitations of coverage. If you use the mail der prescription program of Aetna Rx Home Delivery, LLC, the Aetna Specialty Pharmacy SM specialty drug program, you will be acquiring these prescriptions through an affiliate of Aetna. Aetna s negotiated charge with Aetna Rx Home Delivery and Aetna Specialty Pharmacy may be higher than their cost of purchasing drugs and providing pharmacy services. F these purposes, Aetna Rx Home Delivery's and Aetna Specialty Pharmacy s cost of purchasing drugs takes into account discounts, credits and other amounts that they may receive from wholesalers, manufacturers, suppliers and distributs. Updates to the Drug Fmulary You can obtain fmulary infmation from the Internet at by calling your Member toll-free number. Behavial Health Netwk Behavial health care services are managed by Aetna, except f certain HMO-based health plans in New Yk that are managed by an independently contracted behavial health care ganization. Aetna and the behavial health care ganization are responsible f, in part, making initial coverage determinations and codinating referrals to providers. As with other coverage determinations, you may appeal adverse behavial health care coverage determinations in accdance with the terms of your health plan. The type of behavial health benefits available to you depends upon the terms of your health plan. If your health plan includes behavial health services, you may be covered f mental health conditions and/ drug and alcohol abuse services, including inpatient and outpatient services, partial hospitalizations and other behavial health services. You can determine the type of behavial health coverage available under the terms of your plan and how to access services by calling the Aetna Member number listed on your ID card. If you have an emergency, call 911 your local emergency hotline, if available. F routine services, you may access covered behavial health services available under your health plan by the following methods: Call the toll-free Behavial Health number (where applicable) on your ID card, if no number is listed, call the Member number on your ID card f the appropriate infmation. Where required by your plan, call your PCP f a referral to the designated behavial health provider group. When applicable, an employee assistance student assistance professional may refer you to your designated behavial health provider group. V

8 You can access most outpatient therapy services without a referral pre-authization. However, you should first consult with Member to confirm that any such outpatient therapy services do not require a referral preauthization. Behavial Health Provider Safety Data Available F infmation regarding our Behavial Health provider netwk safety data, please go to and review the quality and patient safety links posted: You may select the quality checks link f details regarding our providers safety repts. Behavial Health Prevention Programs Aetna Behavial Health offers two prevention programs f our members: Perinatal Depression Education, Screening and Treatment Referral Program also known as Mom s to Babies Depression Program and Identification and Referral of Adolescent Members Diagnosed With Depression Who Also Have Co-mbid Substance Abuse Needs. F me infmation on either of these prevention programs and how to use the programs, ask Member f the phone number of your local Care Management Center. Claims Payment f Non-Netwk Providers If your plan provides coverage f services rendered by non-netwk providers, you should be aware that Aetna determines the allowable fee f a non-netwk provider by referring to the Original Medicare approved amount, which is the maximum amount that Original Medicare allows a provider to accept. Charges by a non-netwk provider in excess of the Medicare approved amount will not be covered by Aetna, n are they the responsibility of the member. You may be responsible f any charges Aetna determines are not covered under your plan, as well as any cost sharing outlined in your plan documents. Technology Review Aetna reviews new medical technologies, behavial health procedures, pharmaceuticals and devices to determine which one should be covered by our plans. And we even look at new uses f existing technologies to see if they have potential. To review these innovations, we may: Study medical research and scientific evidence on the safety and effectiveness of medical technologies. Consider position statements and clinical practice guidelines from medical and government groups, including the federal Agency f Health care Research and Quality. Seek input from relevant specialists and experts in the technology. Determine whether the technologies are experimental investigational. You can find out me on new tests and treatments in our Clinical Policy Bulletins. You can find the bulletins at under the Members and Consumers menu. Medically Necessary Medically necessary" means that the service supply is provided by a physician other health care provider exercising prudent clinical judgment f the purpose of preventing, evaluating, diagnosing treating an illness, injury disease its symptoms, and that provision of the service supply is: In accdance with generally accepted standards of medical practice; and Clinically appropriate in accdance with generally accepted standards of medical practice in terms of type, frequency, extent, site and duration, and considered effective f the illness, injury disease; and Not primarily f the convenience of you, f the physician other health care provider; and Not me costly than an alternative service sequence of services at least as likely to produce equivalent therapeutic diagnostic results as to the diagnosis treatment of the illness, injury disease. VI

9 F these purposes generally accepted standards of medical practice means standards that are based on credible scientific evidence published in peerreviewed medical literature generally recognized by the relevant medical community, otherwise consistent with physician specialty society recommendations and the views of physicians practicing in relevant clinical areas and any other relevant facts. Clinical Policy Bulletins Aetna's CPBs describe Aetna's policy determinations of whether certain services supplies are medically necessary experimental investigational, based upon a review of currently available clinical infmation. Clinical determinations in connection with individual coverage decisions are made on a caseby case basis consistent with applicable policies. Aetna's CPBs do not constitute medical advice. Treating providers are solely responsible f medical advice and f your treatment. You should discuss any CPB related to your coverage condition with your treating provider. While Aetna's CPBs are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps other limits. You and your providers will need to consult the benefit plan to determine if there are any exclusions other benefit limitations applicable to this service supply. CPBs are regularly updated and are therefe subject to change. Aetna's CPBs are available online at Precertification Precertification is the process of collecting infmation pri to inpatient admissions and perfmance of selected ambulaty procedures and services. The process permits advance eligibility verification, determination of coverage, and communication with the physician and/ you. It also allows Aetna to codinate your transition from the inpatient setting to the next level of care (discharge planning), to register you f specialized programs like disease management, case management, maternity management programs. In some instances, precertification is used to infm physicians, members and other health care providers about cost-effective programs and alternative therapies and treatments. Certain healthcare services, such as hospitalization outpatient surgery, require precertification with Aetna. When you are to obtain services requiring precertification from a participating provider, the provider is responsible to precertify those services pri to treatment. If your plan covers out-of-netwk benefits and you may self-refer f covered services, it is your responsibility to contact Aetna to precertify those services which require precertification. Refer to your plan documents f specific infmation. Only medically necessary services are covered. A service supply furnished by a particular provider is medically necessary if Aetna determines that it is appropriate f the diagnosis, the care the treatment of the disease injury involved. Note: If your enrolled in an Aetna Golden Choice Plan, please refer to your plan documents f specific infmation regarding precertification. Utilization Review/Patient Management Aetna has developed a patient management program to assist in determining what health care services are covered under the health plan and the extent of such coverage. The program assists you in receiving appropriate health care and maximizing coverage f those health care services. You can avoid receiving an unexpected bill with a simple call to Aetna s Member team. You can find out if your preventive care service, diagnostic test other treatment is a covered benefit befe you receive care just by calling the toll-free number on your ID card. In certain cases, Aetna reviews your request to be sure the service supply is consistent with established guidelines and is included a covered benefit under your plan. We call this utilization management review. We follow specific rules to help us make your health a top concern: Aetna employees are not compensated based on denials of coverage. VII

10 We do not encourage denials of coverage. In fact, our utilization review staff is trained to focus on the risks of members not adequately using certain services. Where such use is appropriate, our Utilization Review/Patient Management staff uses nationally recognized guidelines and resources, such as The Milliman Care Guidelines to guide the precertification, concurrent review and retrospective review processes. To the extent certain Utilization Review/Patient Management functions are delegated to IDSs, IPAs other provider groups ("Delegates"), such Delegates utilize criteria that they deem appropriate. Utilization Review/Patient Management policies may be modified to comply with applicable state law. Only medical directs make decisions denying coverage f services f reasons of medical necessity. Coverage denial letters f such decisions delineate any unmet criteria, standards and guidelines, and infm the provider and you of the appeal process. F me infmation concerning utilization management, you may request a free copy of the criteria we use to make specific coverage decisions by contacting Member. You may also visit to find our Clinical Policy Bulletins and some utilization review policies. Docts health care professionals who have questions about your coverage can write call our Patient Management department. The address and phone number are on your ID card. Concurrent Review The concurrent review process assesses the necessity f continued stay, level of care, and quality of care f members receiving inpatient services. All inpatient services extending beyond the initial certification period will require concurrent review. Discharge Planning Discharge planning may be initiated at any stage of the patient management process and begins immediately upon identification of post-discharge needs during precertification concurrent review. The discharge plan may include initiation of a variety of services/benefits to be utilized by you upon discharge from an inpatient stay. Retrospective Recd Review The purpose of retrospective review is to retrospectively analyze potential quality and utilization issues, initiate appropriate follow-up action based on quality utilization issues, and review all appeals of inpatient concurrent review decisions f coverage of health care services. Aetna's efft to manage the services provided to you includes the retrospective review of claims submitted f payment, and of medical recds submitted f potential quality and utilization concerns. Medicare Advantage Grievance Process Aetna is committed to addressing members' coverage issues, complaints and problems. If you have a coverage issue other problem, call Member at the toll-free number on your ID card. You can also contact Member through the Internet at If Member is unable to resolve your issue to your satisfaction, you can request that your concern be fwarded to the Medicare grievance unit, you may write to the address in your area listed in the Evidence of Coverage. If your issue is regarding a denial of a claim denial of coverage f a health care service, please refer to the Medicare Advantage Appeals Rights below f me infmation. Medicare Advantage Appeal Rights As a member of an Aetna Medicare Advantage plan, you have the right to appeal any decision resulting in Aetna's failure to provide coverage f pay f what you believe are covered benefits and services. These include: Reimbursement f coverage of emergency urgently needed services, out-of-area dialysis services. A denied claim f coverage of health care services that you believe should have been reimbursed by Aetna. VIII

11 Coverage f an item service that you have not received but which you believe should be covered. Any decision to discharge you from the hospital if you believe it is too early to do so. (Note: In this case, a notice will be given to you with infmation about how to appeal to a Medicare Quality Improvement Organization (QIO). You will remain in the hospital while the QIO immediately reviews the decision. You will not be held liable f charges incurred during this period regardless of the outcome of the review. Refer to your Evidence of Coverage f the QIO in your area.) Reduction terminations of coverage f what you feel are medically necessary covered services. Aetna has a Medicare Advantage Standard Appeals Process and a Medicare Advantage Expedited Appeals Process. Following is a general explanation of these imptant processes. Assistance With Appeals If you need assistance understanding following the Medicare Advantage Appeals Process, you can get assistance from a friend, lawyer someone else. There are also groups, such as legal aid services that can help you find a lawyer give you free legal services, if you qualify. You may appoint an individual to act as your authized representative by following the steps below: The individual can be a relative, provider, friend someone else. (Note: A physician may request an expedited appeal on your behalf without being appointed as your representative.) Give us your name, your Medicare claim number, Medicare identification number and a written statement that appoints an individual as your representative. F example, the following statement will suffice as an appointment of representative: "I {your name} appoint {name of representative} to act as my authized representative in requesting an appeal from Aetna regarding denial of coverage f requested services and/ payment." You must sign and date the statement. Your representative must also sign and date the statement unless he/she is an attney. Include the signed statement with your request. Medicare Advantage Standard Appeals Process Aetna must notify you in writing of any decision (partial complete) to deny a claim service. The notice must state the reasons f the denial and also must infm you of your right to file an appeal. If you decide to proceed with the Medicare Advantage Standard Appeals Process, the following steps will occur: 1. You must submit a written request f reconsideration to Aetna. Please refer to the Evidence of Coverage f the appropriate address in your area. You must submit your written request within sixty (60) calendar days of the date of the notice of the initial decision. The sixty (60) day limit may be extended f good cause. Please include in your written request the reason you could not file within the sixty (60) day time frame. 2. Aetna will conduct the reconsideration and notify you in writing of the decision, using the following time frames: Request f : If the appeal is f a denied service, we must notify you of the reconsidered decision as expeditiously as your health requires, but no later than thirty (30) calendar days from receipt of your request. We may extend this time frame by up to fourteen (14) calendar days if you request the extension if we need additional infmation and the extension of time benefits you. Request f Payment: If the appeal is f a denied claim, Aetna must notify you of the reconsidered decision no later than sixty (60) calendar days after receiving your request f a reconsidered decision. Our reconsidered decision will be made by a person(s) not involved in the initial decision. You may present submit relevant facts and/ additional evidence f review either in person in writing to Aetna. IX

12 3. If we decide fully in your fav on a request f a service, we must provide authize the requested service within thirty (30) calendar days of the date we received your request f reconsideration. If we decide fully in your fav on a request f payment, we must make the requested payment within sixty (60) calendar days of the date we received your request f reconsideration. 4. If we decide to uphold the iginal adverse decision, either in whole in part, we will automatically fward the entire file to the MAXIMUS Federal Inc. f a new and impartial review. MAXIMUS Federal Inc. is the Centers f Medicare & Medicaid independent contract f appeal reviews involving Medicare Advantage managed care plans. We must send MAXIMUS Federal Inc. the file within thirty (30) calendar days of a request f services and within sixty (60) calendar days of a request f payment. 5. F cases submitted f review, MAXIMUS Federal Inc. will make a reconsidered decision and notify you in writing of the reasons f the decision. If MAXIMUS Federal Inc. upholds our decision, their notice will infm you of your right to a hearing befe an Administrative Law Judge of the Social Security Administration. If MAXIMUS Federal Inc. decides in your fav, we must: Authize the disputed service within 72 hours from the date we receive notice from MAXIMUS Federal Inc. reversing the decision; Provide the disputed service as expeditiously as your health condition requires, but no later than fourteen (14) calendar days from the date we receive notice from MAXIMUS Federal Inc. reversing the decision; Pay f the disputed service within thirty (30) calendar days from the date we receive notice from MAXIMUS Federal Inc. reversing the decision. If MAXIMUS Federal Inc. does not rule fully in your fav, there are further levels of appeal: 6. If there is at least $110 in controversy, you may request a hearing befe an Administrative Law Judge (ALJ) by submitting a written request to Aetna, MAXIMUS Federal Inc. the entity specified in MAXIMUS Federal Inc. reconsideration notice. The request must be sent within sixty (60) calendar days of the date of MAXIMUS Federal Inc. notice that the reconsidered decision was not in your fav. This sixty (60) day notice may be extended f good cause. 7. Either you Aetna may request a review of an ALJ s decision by the Medicare Appeals Council (MAC), which may either review the decision decline review. 8. If the amount involved is $1090 me, either you Aetna may request that a decision made by the MAC, the ALJ, if the MAC has declined review, be reviewed by a federal district court. 9. Any initial reconsidered decision made by Aetna, MAXIMUS Federal Inc., the ALJ the DAB can be reopened by any party (a) within twelve (12) months, (b) within four (4) years f just cause (c) at any time f clerical crection of an err in cases of fraud. Medicare Advantage Expedited Appeals Process 1. You may file a request f an expedited appeal f the denial of coverage f services you believe you need and where you feel that applying the standard reconsideration process could jeopardize your health. If Aetna decides that the time frame f the standard process could seriously jeopardize your life, health ability to regain maximum function, the review of your request will be expedited. If you disagree with a decision to discharge you from the hospital, see the next section. 2. A physician may file a request f an expedited appeal on your behalf. Aetna must provide an expedited reconsideration if the physician indicates that applying the standard reconsideration process could seriously jeopardize your life, health ability to regain maximum function. X

13 3. Aetna will notify you and/ the physician of its decision as expeditiously as your health condition requires, but no later than 72 hours after receiving the request. We may extend this time frame by up to fourteen (14) calendar days if you request the extension if we need additional infmation, and the extension of time benefits you. 4. To request an expedited appeal, you may call You may fax, mail hand deliver your written request to Aetna. If you write, the 72-hour review time will not begin until your request is received. Please call us f fax/delivery infmation. 5. If Aetna determines that your request is not timesensitive, where your health is not seriously jeopardized, Aetna will notify you verbally and in writing and will automatically begin processing your request under the standard reconsideration process. If you disagree and believe the review should be expedited, you may file a expedited grievance with Aetna. The written notice will include instructions on how to file a grievance. Hospital Discharges When you are first admitted to the hospital, you will receive a document entitled, "An Imptant Message from Medicare". Please read this document carefully. It will describe your rights if you believe you are being asked to leave the hospital too soon. You have the right to request a review by a Quality Improvement Organization (QIO) of any discharge decision. If you request the review by noon of the first wkday after you receive the discharge decision, you do not have to pay f your hospital care until the QIO makes its decision. If you ask f immediate review by the QIO, you will be entitled to QIO process instead of the Medicare Advantage appeals process. If you choose to utilize your Medicare Advantage appeal rights, you would follow the process described above. Quality-of-Care Complaints You also have the right to complain about the quality of medical services provided by netwk providers not meeting professionally recognized standards of care by writing to the QIO. The ganization must review the complaint and infm you your representative of the results of the investigation. They can provide infmation about its review time frames and the steps involved in the process. Refer to your plan documents f the QIO in your area. Medicare Fast Track Appeal Procedure f Skilled Nursing Facility (SNF), Home Health Agency (HHA) Certified Outpatient Rehabilitation Facility Terminations (CORF) When these services are no longer covered by the plan, you will receive a written notice from the provider at least 2 calendar days in advance of termination of coverage. You your authized representative may be asked to sign and date the notice, which outlines your rights. Signing the notice does not mean that you agree that coverage should end. It only means that the notice was provided. As explained in the advance written notice, you have the right to request a fast appeal of the termination of coverage. The fast appeal will be perfmed by the Quality Improvement Organization (QIO). The advance written notice you receive from the provider will give the name and telephone number of the QIO. When the QIO reviews your case, they will look at the medical infmation. The QIO will then give an opinion whether your coverage f services will be terminated on the date that has been provided in the advance written notice. The QIO will make this decision within one full day after they receive the infmation needed to make a decision. If you ask f a fast track appeal from the QIO, they must make the request accding to the following: If the notice is given 2 days befe the coverage ends, the request should be made no later than noon of the day after the provider gave the notice. XI

14 If the notice is given me than 2 days befe the coverage ends, the request should be made no later than noon the day befe the date the Medicare coverage ends. If the QIO decides that the decision to terminate coverage was medically appropriate, you will be responsible f paying the SNF, HHA CORF charges after the termination date on the advance written notice you received from the provider. If the QIO agrees with you, then the plan will continue to provide coverage f the SNF, HHA CORF services f as long as medically necessary. If you do not request the QIO to do a fast track appeal of the discharge by the deadline, you can ask the plan f an Expedited/72-Hour review under the Medicare Advantage Expedited Appeals Process. Member Rights & Responsibilities You have the right to receive a copy of our Member Rights and Responsibilities Statement. This infmation is available to you online at You can also obtain a print copy by contacting Member at the number on your ID card. Member To file a compliant an appeal, f additional infmation regarding copayments and other charges, infmation regarding benefits, to obtain copies of plan documents, infmation regarding how to file a claim f any other question, you can contact Member at the toll-free number on your ID card, us from your secure member website, Aetna Navigat at Click on Contact Us after you log in. When you require assistance from an Aetna representative, call us during regular business hours at the number on your ID card. Our representatives can: Answer benefits questions Help you get referrals Find care outside your area Advise you on how to file complaints and appeals Connect you to behavial health services (if included in your plan) Find specific health infmation Provide infmation on our Quality Management program, which evaluates the ongoing quality of our services Interpreter/Hearing Impaired Interpreter Aetna can help explain benefit and provider infmation in up to 140 languages! If you require Spanish speaking assistance, please contact us at the toll free number located on your ID card and follow the prompts. If you require assistance in a language other than Spanish please call us at the toll free number that is located on your ID card and ask f an interpreter. Hearing Impaired TDD: (hearing impaired only) Quality Management Programs Call Aetna to learn about the specific quality effts we have under way in your local area. Ask Member f the phone number of your regional Quality Management office. If you would like infmation about Aetna Behavial Health s Quality Management Program, ask Member f the phone number of your Care Management Center Quality Management office. Privacy Notice Aetna considers personal infmation to be confidential and has policies and procedures in place to protect it against unlawful use and disclosure. By personal infmation, we mean infmation that relates to your physical mental health condition, the provision of health care to you, payment f the provision of health care to you. Personal infmation does not include publicly available infmation infmation that is available repted in a summarized aggregate fashion but does not identify you. When necessary appropriate f your care treatment, the operation of our health plans, other related activities, we use personal infmation internally, share it with our affiliates, and disclose it to health care providers (docts, dentists, pharmacies, XII

15 hospitals and other caregivers), pays (health care provider ganizations, employers who spons selffunded health plans who share responsibility f the payment of benefits, and others who may be financially responsible f payment f the services benefits you receive under your plan), other insurers, third party administrats, vends, consultants, government authities, and their respective agents. These parties are required to keep personal infmation confidential as provided by applicable law. Participating netwk providers are also required to give you access to your medical recds within a reasonable amount of time after you make a request. Some of the ways in which personal infmation is used include claims payment; utilization review and management; medical necessity reviews; codination of care and benefits; preventive health, early detection, and disease and case management; quality assessment and improvement activities; auditing and anti-fraud activities; perfmance measurement and outcomes assessment; health claims analysis and repting; health services research; data and infmation systems management; compliance with legal and regulaty requirements; fmulary management; litigation proceedings; transfer of policies contracts to and from other insurers, HMOs and third party administrats; underwriting activities; and due diligence activities in connection with the purchase sale of some all of our business. We consider these activities key f the operation of our health plans. To the extent permitted by law, we use and disclose personal infmation as provided above without your consent. However, we recognize that you may not want to receive unsolicited marketing materials unrelated to your health benefits. We do not disclose personal infmation f these marketing purposes unless you consent. We also have policies addressing circumstances in which you are unable to give consent. To obtain a hard copy of our Notice of Privacy Practices, which describes in greater detail our practices concerning use and disclosure of personal infmation, please write to Aetna's Legal Suppt Department at 151 Farmington Avenue, W121, Hartfd, CT You can also visit our Internet site at You can link directly to the Notice of Privacy Practices by Plan Type, by selecting the "Privacy Notices" link at the bottom of the page, and selecting the link that cresponds to your specific plan. XIII

16

17 Additional Imptant Disclosure Infmation Aetna Golden Medicare Plan Only Please Read XV

18

19 Additional Imptant Disclosure Infmation Aetna Golden Medicare Plan Only Cost Sharing You are responsible f any copayments, coinsurance and deductibles f covered services. These obligations are paid directly to the provider facility at the time the service is rendered. Copayment, coinsurance and deductible amounts are listed in your benefits summary and plan documents. Role of Primary Care Physicians ("PCPs") F most Aetna Medicare HMO plans, you are required to select a PCP who participates in the netwk. The PCP can provide primary health care services as well as codinate your overall care. You should consult your PCP when you are sick injured to help determine the care that is needed. Your PCP should issue referrals to participating specialists and facilities f certain services. F some services, your PCP is required to obtain pri authization from Aetna. Except f those benefits described in the plan documents as direct access benefits, plans with self-referral to participating providers (Aetna Open Access Aetna Choice POS), plans that include benefits f nonparticipating provider services (Aetna Choice POS QPOS), in an emergency, you will need to obtain a referral authization ("referral ") from your PCP befe seeking covered nonemergency specialty hospital care. Check your plan documents f details. Referral Policy If your plan documents state referrals are required, please review the following imptant points regarding referrals. The referral is how your PCP arranges f you to be covered f necessary, appropriate specialty care and follow-up treatment. You should discuss the referral with your PCP to understand what specialist services are being recommended and why. If the specialist recommends any additional treatments tests that are covered benefits, you may need to get another referral from your PCP pri to receiving the services. If you do not get another referral f these services, you may be responsible f payment. Except in emergencies, all hospital admissions and outpatient surgery require a pri referral from your PCP and pri authization by Aetna. If it is not an emergency and you go to a doct facility without a referral, you must pay the bill. Referrals are valid f one year as long as you remain an eligible member of the plan; the first visit must be within 90 days of referral issue date. In plans without out-of-netwk benefits, coverage f services from nonparticipating providers requires pri authization by Aetna in addition to a special nonparticipating referral from the PCP. When properly authized, these services are fully covered, less the applicable cost-sharing. The referral provides that, except f applicable cost sharing, you will not have to pay the charges f covered benefits, as long as the individual seeking care is a member at the time the services are provided. Emergency Care If you need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the wld. An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity such that a prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the XVII

20 absence of immediate medical attention to result in serious jeopardy to the person's health, with respect to a pregnant woman, the health of the woman and her unbn child. Whether you are in out of an Aetna Golden Medicare plan service area, we simply ask that you follow the guidelines below when you believe you need emergency care. Call the local emergency hotline (ex. 911) go to the nearest emergency facility. If a delay would not be detrimental to your health, call your PCP. Notify your PCP as soon as possible after receiving treatment. If you are admitted to an inpatient facility, you a family member friend on your behalf should notify your PCP Aetna as soon as possible. What to Do Outside Your Aetna Golden Medicare Plan Service Area If you are traveling outside of your Aetna Golden Medicare Plan service area, you are covered f emergency and urgently needed care. Urgent care may be obtained from a private practice physician, a walk-in clinic, an urgent care center an emergency facility. Certain conditions, such as severe vomiting, earaches, se throats fever, are considered urgent care" outside your Aetna Golden Medicare Plan service area and are covered in any of the above settings. If, after reviewing infmation submitted to us by the provider that supplied care, the nature of the urgent emergency problem does not qualify f coverage, it may be necessary to provide us with additional infmation. We will send you an Emergency Room Notification Rept to complete, a Member representative can take this infmation by telephone. Follow-up Care after Emergencies All follow-up care should be codinated by your PCP. Follow-up care with nonparticipating providers is only covered with a referral from your PCP (when required by your plan) pri authization from Aetna. Whether you were treated inside outside your Aetna Golden Medicare Plan service area, if your plan requires referrals, you must obtain a referral befe any follow-up care can be covered. If your plan does not require referrals you should contact Aetna at the number on your ID card befe care is received at nonnetwk facilities. Suture removal, cast removal, X-rays and clinic and emergency room revisits are some examples of follow-up care. After-Hours Care You may call your doct s office 24 hours a day, 7 days a week if you have medical questions concerns. You may also consider visiting participating Urgent Care facilities. How Aetna Compensates Your Health Care Provider All the physicians are independent practicing physicians that are neither employed n exclusively contracted with Aetna. Individual physicians and other providers are in the netwk by either directly contracting with Aetna and/ affiliating with a group ganization that contract with us. Participating providers in our netwk are compensated in various ways: Per individual service case (fee f service at contracted rates). Per hospital day (per diem contracted rates). Capitation (a prepaid amount per member, per month). Through Integrated Delivery Systems (IDS), Independent Practice Associations (IPA), Physician Hospital Organizations (PHO), Physician Medical Groups (PMG), behavial health ganizations and similar provider ganizations groups. Aetna pays these ganizations, which in turn may reimburse the physician, provider ganization facility directly indirectly f covered services. In such arrangements, the group ganization has a financial incentive to control the cost of care. One of the purposes of managed care is to manage the cost of health care. Incentives in compensation arrangements with physicians and health care providers are one method by which Aetna attempts to achieve this goal. XVIII

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