Aetna Better Health - PDF document

Aetna Better Health SM Premier Plan (Medicare-Medicaid Plan) is a health plan that contracts SummMry of Bene�Ps AETNA BETTER HEALTH SM PREMIER PLAN www.aetnabetterhealth.com/illinois IL - 13 - - 07 - ENG H2506_14_120 www.aetnabetterhealth.com/illinoisHelpful informationAetna Better Health Premier PlanMember Services1-866-600-2139 (Poll free)Representatives available 24 hours a day, 7 days a weekAddressAetna Better Health Premier PlanOne South Wacker DriveSuite 1200, Mail Stop F646COicMgo, HI 60606Services for the Hearing ImpairedIllinois Relay 7-1-1Enrollment and Application ServicesIllinois Client Enrollment Broker (ICEB)1-877-E12-8880 (Poll free)TTY: 1-866-565-8576Transportation ServicesMedicMl TrMnsporPMPion MMnMgemenP, HncBNon-Emergency TrMnsporPMPion1-888-D13-1612 (Poll free)Dental ServicesDentaQuest1-800-416-E18D (Poll free)Behavioral Health Services1-866-600-2139 (Poll free)Vision ServicesMarch Vision1-888-4E3-4070 (Poll free)Pharmacy ServicesAetna Better Health Premier PlanCall Member Services1-866-600-2139 (Poll free)Prescriptions by MailCVS CaremarkPO Box 2110PiPPsburgO, PA 1D230-2110 TTY: 1-800-899-2114MondMy POrougO FridMy8 MBmB Po D pBmBLanguage Interpretation ServicesIncluding Sign Language Interpretation and CART ReportingCall Aetna Better Health Premier Plan Member Services1-866-600-2139 (Poll free)Representatives available 24 hours a day, 7 days a weekAppeals and GrievancesAetna Better Health Premier PlanAPPn: AppeMls Mnd GrievMnces MMnMgerOne South Wacker DriveMail Stop F646COicMgo, HI 60606 1-866-600-2139Hllinois RelMy 7-1-1 (OeMring impMired)To make a request for a fair hearing:Hllinois GepMrPmenP of HeMlPOcMre and Family Services BureMu of AssisPMnce HeMrings 401 South Clinton, Sixth FloorCOicMgo, HI 606071-800-43D-0774 (Poll free)TTY: 1-877-734-7429 Fraud and Abuse Hotline1-877-436-81D4 (Poll free) AETNA BETTER HEALTH® PREMIER PLAN : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 1 IL - 13 - 11 - 07 - ENG CMS ACCEPTED H2506_14_ 120 ? This is a summary of health services covered by Aetna Better Health Premier Plan for 2014 . This is only a summary. Please read the Member Handbook for the full list of benefits.  Aetna Better Health Premier Plan is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees. It is for people with both Medicare and Medicaid. The Aetna Better Health Premier Plan will be a v a i l a ble to ind i vidua l s who m ee t all of the f ol l owing c rit e ri a : o A ge 21 a nd old e r a t t he t i me of e nrollm e nt; o Enti t led to b e n e fits under M e dic a r e P a rt A a nd e n r ol l e d und e r M e di c a re Par ts B a nd D, a nd re ce iv i n g full M e dic a id ben e fits; a nd o En r ol l e d in the M e dic a id Aid to t he Ag e d, B l i nd, a nd Dis a bled ( A B D) ca t e g o r y of a ss i stan c e. o Eli g ib l e populations i n c lude:  B e n e fi c ia r i e s who m ee t a ll other D e monstr a t i on c r i t e ria a nd a re in t he foll o wing  M e dic a id 1915( c ) wa iv e r s:  P e rsons w ho a re Eld e r l y ;  P e rsons w i t h Dis a bi l i t ie s ;  P e rsons w i t h H I V/ A I D S ;  P e rsons w i t h B r a in I nj u r y ; a nd  P e rsons re sid i ng in S up p ortive L iv i n g Fac i l i t ies. o I ndiv i du a ls wi t h End St a g e R e n a l Dise a s e ( E S R D ) a t t he t i me of e nrollm e n t.  U nder Aetna Better Health Premier Plan you can get your Medicare and Medicaid services in one health plan. A n Aetna Better Health Premier Plan car e management team, led by a car e manager will help manage your health care needs. Aetna Better Health ® Premier Plan : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 2 IL - 13 - 11 - 07 - ENG H2506_14_ 120 ?  This is not a complete list. The benefit information is a brief summary, not a com plete description of benefits. For more information contact the plan or read the Member Handbook.  Limitations and restrictions may apply. For more information, call Member Services or read the Aetna Better Health Premier Plan Member Handbook.  Benefits, List of Covered Drugs, and pharmacy and provider networks may change from time to time throughout the year and on January 1 of each year. We will notify you, by mail and on our website , www. aetnabetterhealth.com/ i llinois , of any changes.  You can ask for this information in other formats, such as Braille or large print. Call 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week . The call is free.  You can get this document in Spanish, or speak with someone about this information in other languages fo r free. Call 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week . The call is free.  Usted puede obtener este documento en español, o hablar gratuitamente con una persona en otros idiomas sobre esta información. Llame a S ervicios al Miembro al 1 - 866 - 600 - 2139 y TTY/TDD al 7 - 1 - 1, 24 horas al día, siete días de la semana. La llamada es gratis.  Aetna Better Health Premier Plan is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees. Aetna Better Health ® Premier Plan : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 3 IL - 13 - 11 - 07 - ENG H2506_14_ 120 ? The following chart lists frequently asked questions. Frequently Asked Questions (FAQ) Answers What is a Medicare - Medicaid Plan? A Medicare - Medicaid Plan is an organization made up of doctors, hospitals, pharmacies, providers of long - term services, and other providers. It also has care coordinators to help you manage all your providers and services. They all work together to provide the care you need. What is a n Aetna Better Health Premier Plan care manager ? A n Aetna Better Health Premier Plan care manager is one main person for you to contact. This person helps manage all your providers and services and makes sure you get what you need. What are long - term services and supports? Long - term services and supports are services provided through a Long Term Care Facility or through a Home and Community Based Waiver. Enrollees have the option to receive long - term services and supports (LTSS) in the least restrictive setting when appropriate, with a preference for the home and the community, and in accordance with the Enrollee’s wishes and Care Plan. Will you get the same Medicare and Medicaid benefits in Aetna Better Health Premier Plan that you get now? You will get your covered Medicare and Medicaid benefits directly from Aetna Better Health Premier Plan . Y ou will work with a team of providers who will help determine what services will best meet your needs. This means that some of the services you get now may change. When you enroll in Aetna Better Health Premier Plan , you and your care team will work toge ther to develop an Individualized Care Plan to address your health and support needs. During this time, you can keep seeing your doctors and getting your current services for 180 days, or until your care plan is complete. When you join our plan, if you are taking any Medicare Part D prescription drugs that Aetna Better Health Premier Plan does not normally cover, you can get a temporary supply. We will help you get another drug or get an exception for Aetna Better Health Premier Plan to cover your drug, if medically necessary. Aetna Better Health ® Premier Plan : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 4 IL - 13 - 11 - 07 - ENG H2506_14_ 120 ? Frequently Asked Questions (FAQ) Answers Can you go to the same doctors you see now? Often that is the case. If your providers (including doctors, therapists, and pharmacies) work with Aetna Better Health Premier Plan and have a contract with us, you can keep going to them. Providers with an agreement with us are “in - network.” You must use the providers in Aetna Better Health Premier Plan ’s network. If you need urgent or emergency care or out - of - area dialysis services, you can use providers outside of Aetna Better Health Premier Plan 's network . If Aetna Better Health Premier Plan is unable to provide necessary medical/surgical services covered under your benefits, Aetna Better Health Pre mier Plan will cover these services out of network for you, for as long as Aetna Better Health Premier Plan is unable to provide the services in network. To find out if your doctors are in the plan’s networ k, call Member Services at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1, 24 hours a day, 7 days a week or read Aetna Better Health Premier Plan’ s Provider and Pharmacy Directory on our web site at www. aetnabetterhealth.com/ illinois . If Aetna Better Health Premier Plan is new for you, you can continue see ing the doctors you go to now for the next 180 days or until you and your care manager decide who is best to care for you and your health needs. What happens if you need a service but no one in Aetna Better Health Premier Plan ’s network can provide it? Most services will be provided by our network providers. If you need a service that cannot be provided within our network, Aetna Better Health Premier Plan will pay for the cost of an out - of - network provider. Where is Aetna Better Health Premier Plan avai lable? The service area for this plan includes: Cook County, DuPage County, Kane County , Kankakee County and Will County in Illinois . You must live in one of these areas to join the plan. Aetna Better Health ® Premier Plan : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 5 IL - 13 - 11 - 07 - ENG H2506_14_ 120 ? Frequently Asked Questions (FAQ) Answers Do you pay a monthly amount (also call ed a premium) und er Aetna Better Health Premier Plan? You will not pay any monthly premiums to Aetna Better Health Premier Plan for your health coverage. What is prior authorization? Prior authorization means that you must get approval from Aetna Better Health Premier Plan before you can get a specific service or drug or see an out - of - network provider. Aetna Better Health Premier Plan may not cover the service or drug if you don’t get approval. If you need urgent or emergency care or out - of - area dialysis services, you don't need to get approval first. What is a referral? A referral means that your primary care provider must give you approval to see someone that is not your primary care provider. If you don’t get approval, Aetna Better Health Premier Plan may not cover the services. There are certain specialists in which you do not need a referral, such as women health specialists. For more information on when a referral is necessary, see the Member Handbook. Aetna Better Health ® Premier Plan : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 6 IL - 13 - 11 - 07 - ENG H2506_14_ 120 ? Frequently Asked Questions (FAQ) Answers Who should you contact if you have questions or need help? If you have general questions or questions about our plan, services, billing, or member cards, please call Aetna Better Health Premier Plan Member Services: CALL 1 - 866 - 600 - 2139 TTY/TDD IL Relay 7 - 1 - 1, 24 hours a day, 7 days a week. The call is free. Member Services also has free language interpreter services available for people who do not speak English. TTY TTY/TDD Relay 7 - 1 - 1 . This number is for people who have hearing or speaking problems. You must have special telephone equipmen t to call it. For more information call Member Services and we can answer any questions you have. Call 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1, 24 hours a day, 7 days a week. The call is free. Aetna Better Health ® Premier Plan : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 7 IL - 13 - 11 - 07 - ENG H2506_14_ 120 ? Frequently Asked Questions (FAQ) Answers Who should you contact if you have questions or need help? (continued) If you have questions about your health, please call the Nurse Advice Call line: CALL Call 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1, 24 hours a day, 7 days a week. The call is free. F ollow the prompts for the Nurse Advice Line . Member Services also has free languag e interpreter services available for people who do not speak English. TTY TTY/TDD IL Relay 7 - 1 - 1, 24 hours a day, 7 days a week. The call is free. Member Services also has free language interpreter services available for people who do not speak English. If you need immediate behavioral health crises services , please call 911 or the Behavioral Health Crisis Line: CALL Call 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1, 24 hours a day, 7 days a week. The call is free. Press 9 for the Nurse Advice Line. Member Ser vices also has free language interpreter services available for people who do not speak English. TTY TTY/TDD IL Relay 7 - 1 - 1, 24 hours a day, 7 days a week. Member Services also has free language interpreter services available for people who do not speak English. Aetna Better Health ® Premier Plan : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 8 IL - 13 - 11 - 07 - ENG H2506_14_ 120 ? The following chart is a quick overview of what services you may need, your costs and rules about the benefits. Health need or problem Services you may need Your costs for in - network providers Limitations, exceptions, & benefit information (rules about benefits) You want to see a doctor Visits to treat an injury or illness $ 0 100% - no limitations /no authorizations required if seeing a network provider Wellness visits, such as a physical $ 0 100% - no limitations/no authorizations required if seeing a network provider Transportation to a doctor’s office $ 0 100% - prior authorization required Specialist care : Prof - B ehavioral H ealth Non - Medical Prof - Cardiac Rehab ilitation Prof - Chiro practic Prof - Intensive Cardiac Rehab ilitation Prof - Orthopedic Shoes Prof - Preventative Services Prof - Lab Tests and services Prof - Pulmonary Rehab ilitation Prof - Routine Foot C are $ 0 In some cases an authorization maybe required None 36 visit limit 12 per y ear 36 visit limit 5 per year with Diabetic d iagnosis None None 36 visit limit Routine F oot Care Diagnosis Restriction - 1 visit every 3 months Aetna Better Health ® Premier Plan : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 9 IL - 13 - 11 - 07 - ENG H2506_14_ 120 ? Health need or problem Services you may need Your costs for in - network providers Limitations, exceptions, & benefit information (rules about benefits) Care to keep you from getting sick, such as flu shots $ 0 1 00% - no limitations/no authorizations required if seeing a network provider “Welcome to Medicare” preventive visit (one time only) $ 0 100% - no limitations/no authorizations required if seeing a network provider You need medical tests Lab tests, such as blood work $ 0 100% - prior authorization may be requi red for certain tests X - rays or other pictures, such as CAT scans $ 0 100% - some radiology requests require authorizations Screening tests, such as tests to check for cancer $ 0 100% - no authorizations required if seeing a network provider Aetna Better Health ® Premier Plan : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 10 IL - 13 - 11 - 07 - ENG H2506_14_ 120 ? Health need or problem Services you may need Your costs for in - network providers Limitations, exceptions, & benefit information (rules about benefits) You need drugs to treat your illness or condition There may be limitations on the types of drugs covered. Please see Aetna Better Health Premier Plan ’s List of Covered Drugs (Drug List) for more information. Generic drugs (no brand name) $0 for a 30 - day supply. Extended day supplies of covered drugs are available at network , retail and mail order pharmacies. These drugs are usually considered maintenance drugs. Your copay for the extended day supply is the same as the 30 - day supply. Some drugs have coverage rules or have limits on the amount you can get. For example: • For s ome drugs, you or your doctor must get approval from the plan before you fill your prescription. • Sometimes the plan limits the amount of a drug you can get. Step therapy: Sometimes the plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second. Aetna Better Health ® Premier Plan : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 11 IL - 13 - 11 - 07 - ENG H2506_14_ 120 ? Health need or problem Services you may need Your costs for in - network providers Limitations, exceptions, & benefit information (rules about benefits) Brand name drugs $ 0 for a 30 - day supply. Extended day supplies of covered drugs are available at network retail and mail order pharmacies. These drugs are usually considered maintenance drugs. Your copay for the extended day supply is the same as the 30 day supply. Some drugs have coverage rules or have limits on the amount you can get. For example: • For some drugs, you or your doctor must get approval from the plan before you fill your prescription. • Sometimes the plan limits the amount of a drug you can get. Step therapy: Sometimes the plan re quires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will co ver the second . Aetna Better Health ® Premier Plan : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 12 IL - 13 - 11 - 07 - ENG H2506_14_ 120 ? Health need or problem Services you may need Your costs for in - network providers Limitations, exceptions, & benefit information (rules about benefits) Over - the - counter drugs $ 0 100% (in accordance with Medicaid covered benefits) Medicare Part B prescription drugs covered by Aetna Better Health Premier Plan . Part B drugs include drugs given by your doctor in his or her office, some oral cancer drugs, and some drugs used with certain medical equipment. Read the Member Handbook for more information on these drugs . $ 0 You need therapy after a stroke or accident Occupational, physical, or speech therapy $ 0 100% You need emergency care Emergency room services $ 0 E mergency room services can be provided by in network and out of network providers and do not require prior authorization Ambulance services $ 0 Emergency ambulance services do not require a prior authorization Aetna Better Health ® Premier Plan : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 13 IL - 13 - 11 - 07 - ENG H2506_14_ 120 ? Health need or problem Services you may need Your costs for in - network providers Limitations, exceptions, & benefit information (rules about benefits) Urgent care $ 0 Urgent Care services can be provided by in network and out of network providers and do not require prior authorization You need hospital care Hospital stay $ 0 Emergency admissions, hospitals are required to notify the health plan. Elective admissions require prior authorization. Doctor or surgeon care $ 0 100% - no limitations/no authorizations required if seeing a network provider You need help getting better or have special health needs Rehabilitation services $ 0 Rehab ilitation = limit of 36 visits - in network provider (cardiac, pulmonary) Chiropractic = limit of 12 visits - in network provider Medical equipment for home care $ 0 100 % - with prior authorization requirements Skilled nursing care $ 0 100% - SNF Co - pay - Days 21 - 100 = Medicare and Medicaid = 0 co - pay You need eye care Eye exams $ 0 1 exam every 12 months Glasses or contact lenses $ 0 1 pair of glasses or contacts every 24 months Aetna Better Health ® Premier Plan : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 14 IL - 13 - 11 - 07 - ENG H2506_14_ 120 ? Health need or problem Services you may need Your costs for in - network providers Limitations, exceptions, & benefit information (rules about benefits) You need dental care Dental check - ups $0 Prevent ive (exams, cleaning, x - rays) 2/year You need hearing/auditory services Hearing screenings $0 100% - no limitations/no authorizations required if seeing a network provider Hearing aids $0 100% - prior authorization required (in accordance with Medicaid covered benefits) You have a chronic condition, such as diabetes or heart disease Services to help manage your disease $0 100% - no limitations/no authorizations required if seeing a network provider Diabetes supplies and services $0 100% - no limitations/no authorizations required if seeing a network provider You have a mental health condition Mental or behavioral health services $0 100% - no limitations/no authorizations required if seeing a network provider You have a substance abuse problem Substance abuse services $0 100% - no limitations/no authorizations required if seeing a network provider You need long - term mental health services Inpatient care for people who need mental health care $0 100% - no limitations/no authorizations required You need durable medical equipment (DME) Wheelchairs $0 100% - prior authorization required Canes $0 100% - no limitations/no authorizations required if seeing a network provider Aetna Better Health ® Premier Plan : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 15 IL - 13 - 11 - 07 - ENG H2506_14_ 120 ? Health need or problem Services you may need Your costs for in - network providers Limitations, exceptions, & benefit information (rules about benefits) Crutches $0 100% - no limitations/no authorizations required if seeing a network provider Walkers $0 100% - no limitations/no authorizations required if seeing a network provider Oxygen $0 100% - no limitations/no authorizations required if seeing a network provider Aetna Better Health ® Premier Plan : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 16 IL - 13 - 11 - 07 - ENG H2506_14_ 120 ? Health need or problem Services you may need Your costs for in - network providers Limitations, exceptions, & benefit information (rules about benefits) You need help living at home Meals brought to your home 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required Home services, such as cleaning or housekeeping 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required Changes to your home, such as ramps and wheelchair access 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required Personal care assistant (You may be able to employ your own assistant. Call Member Services for more information.) 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required Training to help you get paid or unpaid jobs 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required Home health care services 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required Services to help you live on your own 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required Aetna Better Health ® Premier Plan : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 17 IL - 13 - 11 - 07 - ENG H2506_14_ 120 ? Health need or problem Services you may need Your costs for in - network providers Limitations, exceptions, & benefit information (rules about benefits) Adult day services or other support services 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required You need a place to live with people available to help you Assisted living or other housing services 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required Nursing home care 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required Your caregiver needs some time off Respite care 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required Aetna Better Health ® Premier Plan : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 18 IL - 13 - 11 - 07 - ENG H2506_14_ 120 ? Other services that Aetna Better Health Premier Plan covers: Other services Aetna Better Health Premier Plan covers (This is not a complete list. Call Member Services or read the Member Handbook to find out about other covered services.) Podiatry - expanded benefit 1 annual visit for routine foot care Over T he Counter Products $20 per month through mail - order catalog service Health Education W ide array of health and education tools and programs that is available to members at no additional cost Smoking and Tobacco Use Cessation Medically necessary cessation counseling sessions (up to 50 per year), nicotine patches, gum, and lozenges, as well as certain pharmacy medications without needing prior authorization Health and Wellness Access to the Silver & Fit program at no cost at participating locations Nursing Hotline Access to a registered nurse 24 hours a day, 7 days a week, 365 days a year Nutritional Education Health and nutrition tools and programs that is available to members at no additional cost Aetna Better Health ® Premier Plan : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 19 IL - 13 - 11 - 07 - ENG H2506_14_ 120 ? Services that Aetna Better Health Premier Plan does not cover: Services Aetna Better Health Premier Plan does not cover (This is not a complete list. Call Member Services to find out about other excluded services.) Hospice Services Covered under Medicare fee for service Your rights as a member of the plan As a member of Aetna Better Health Premier Plan you have certain rights. You can exercise these rights without being punished. You can also use these rights without losing your health care services. We will tell you about your rights at least on c e a year. For more information on your rights, please r ead the Member Handbook. Your rights include, but ar e not limited to, the following:  You have a right to respect, fairness and dignity. This includes: o The right to get covered services without concern about race, ethnicity, national origin, religion, gender, age, mental or physical disability, sexual orientation, genetic information, ability to pay, or ability to speak English o The right to request information in other formats (e.g., audio CD ‑ ROM, large print, cassette, Braille) o The right to be free fro m any form of restraint or seclusion o The right not to be billed by providers  You have the right to get information about your health care. This includes information on treatment and your treatment options. This information should be in a format you can u nderstand. These rights include getting information on: o Description of the services we cover o How to get services o How much services will cost you o Names of health care providers and care managers Aetna Better Health ® Premier Plan : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 20 IL - 13 - 11 - 07 - ENG H2506_14_ 120 ?  You have t he right to make decisions about your care, including refusing treatment. This includes the right: o To choose a Primary Care Provider (PCP) and you can change your PCP at any time o To see a women’s health care provider without a referral o To get your covered services and drugs quickly o To know about all treatment options, no matter what they cost or whether they are covered o To refuse treatment, even if your doctor advises against it o To stop taking medicine o To ask for a second opinion . Aetna Better Health Premier Plan will pay for the cost of your second opinion visit.  You have the right to timely access to care that does not have any communication or physical access barriers. This includes the right to: o Get medical care timely o Get in and out of a health care provider’ s office. This means barrier free access for people with disabilities, in accordance with the Americans with Disabilities Act o Have interpreters to help with communication with your doctors and your health plan.  You have the right to seek emergency and urgent care when you need it. This means: o You have the right to get emergency services without prior approval in an emergency o You have the right to see an out of network urgent or emergency care provider, when necessary  You have a right to confidentiality and privacy. This includes: o The right to ask for and get a copy of your medical records in a way that you can understand and to ask for your records to be changed or corrected. o The right to have your personal health information kept private.  You have the right to make complaints about your covered services or care. This includes the right to: o File a complaint or grievance against us or our providers o Ask for a state fair hearing o Get a detailed reason for why services were denied Aetna Better Health ® Premier Plan : Summary of Benefits If you have questions , please call Aetna Better Health Premier Plan’s Member Services Department at 1 - 866 - 600 - 2139 , TTY/TDD IL Relay 7 - 1 - 1 24 hours a day, 7 days a week. The call is free. For more information , visit our website www.aetnabetterhealth.com/illinois . 21 IL - 13 - 11 - 07 - ENG H2506_14_ 120 ? For more information about your rights, you can read the Aetna Better Health Premier Plan Member Handbook. If you have questions, you can also call Aetna Better Health Premier Plan Member Services. If you have a complaint or think we should cover something we denied If you have a complaint or think Aetna Better Health Premier Plan should cover something we denied, call Aetna Better Health Premier Plan Member Services toll - free number at 1 - 866 - 600 - 2139. For questions about your rights, you can read the Aetna Better Health Premier Plan Member Handbook . You can also call Aetna Better Health Premier Plan Member Services. For information and questions on for complaints, grievances, and appeals. You can call Aetna Better Health Premier Plan Member Services If you suspect fraud Most health care professionals and organizations that provide services are honest. Unfortunately, there may be some who are dishonest. If you think a doctor, hospital or other pharmacy is doing something wrong, please contact us.  Call us atlan na&#xp-50;me Member Services. Phone numbers are on the cover of this summary.  Or, call Medicare at 1 - 800 - MEDICARE (1 - 800 - 633 - 4227). TTY users should call 1 - 877 - 486 - 2048. You can call these numbers for free, 24 hours a day, 7 days a week.  Or, call the office of Auditor General’s Office at 1 - 855 - 217 - 1895 or contact them by email at OAG.Hotline@Illinois.gov 1-855-271-6603 (toll free)