HMO - Aetna Medicare

Section 1 – Introduction
This directory provides a list of Aetna Medicare
HMO and PPO network providers. To get detailed
information about your health care coverage, please
see your Evidence of Coverage.
If you are enrolled in a standard Aetna Medicare
Health Maintenance Organization (HMO) plan,
you will have to choose one of our network providers
that are listed in this directory to be your Primary Care
{Physician/Provider} (PCP). The term “PCP” will be
used throughout this directory. Generally, you must
get your health care coverage from your PCP. Your
PCP will issue referrals to participating specialists and
facilities for certain services. For some services, your
PCP is required to obtain prior authorization from
Aetna. You must use network providers except for
urgent care or out-of-area urgent care/renal dialysis.
Except for those benefits described in your plan
documents as direct-access benefits, or in an
emergency, you will need to obtain a referral from
your PCP before seeking covered non-emergency
specialty or hospital care. Check your Evidence of
Coverage for details.
If you are enrolled in an Aetna Medicare (HMO)
Open Access plan, you are not required to choose a
primary care physician (PCP) and are free to visit
network providers without a referral to receive covered
services. You must use network providers except for
urgent care or out-of-area urgent care/renal dialysis.
If you are enrolled in an Aetna Medicare
Preferred Provider Organization (PPO) plan, you
have the flexibility to choose either network providers
at lower out-of-pocket costs, or out-of-network
providers at a higher cost sharing level. With the
exception of emergencies or urgent care, it may cost
PPO members more to get care from out-of-network
providers. You can use any Aetna Medicare PPO
network PCP and pay the plan's lower primary doctor
visit copay. Although you are not required to select a
PCP, you are encouraged to do so.
The “network providers” listed in this directory have
agreed to provide you with your health care coverage.
You may go to any of our network providers listed in
this directory; however, some services may require a
referral. If you have been going to one network
provider, you are not required to continue going to
that same provider. In some cases, you may get
covered services from non-network providers. In cases
where non-contracting providers submit a bill directly
to you, you should not pay the bill, but submit it to
Aetna Medicare for processing and determination of
your financial liability, if any.
Certain healthcare services, such as hospitalization or
outpatient surgery, require precertification with Aetna.
This means the service must be approved by Aetna
before it will be covered under the plan. Check your
Evidence of Coverage for a complete list of services
that require this approval. When you are to obtain
services requiring precertification from a participating
provider, the provider is responsible to precertify those
services prior to treatment. If your plan covers out-ofnetwork
benefits and you may self-refer for covered
services, it is your responsibility to contact Aetna to
precertify those services which require precertification.
If you need emergency care, you are covered 24 hours
a day, 7 days a week, anywhere in the world. Whether
you are in or out of an Aetna Medicare 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) or 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 or a
family member or friend on your behalf should
notify your PCP or Aetna as soon as possible.
If you are traveling outside of the Aetna Medicare
(HMO) (PPO) plan service area, you are covered for
emergency and urgently needed care. Urgent care
may be obtained from a private practice physician, a
walk-in clinic, an urgent care center or an emergency
facility. If, after reviewing information submitted to us
by the provider that supplied care, the nature of the
urgent or emergency problem does not qualify for
coverage, it may be necessary to provide us with
additional information.
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