[PDF] Directory - Aetna Medicare

Additional Important DisclosureInformationAetna Golden Medicare Plan OnlyCost SharingYou are responsible for any copayments, coinsuranceand deductibles for covered services. These obligationsare paid directly to the provider or facility at the timethe service is rendered. Copayment, coinsurance anddeductible amounts are listed in your benefitssummary and plan documents.Role of Primary Care Physicians ("PCPs")For most Aetna Medicare HMO plans, you are requiredto select a PCP who participates in the network. ThePCP can provide primary health care services as well ascoordinate your overall care. You should consult yourPCP when you are sick or injured to help determinethe care that is needed. Your PCP should issue referralsto participating specialists and facilities for certainservices. For some services, your PCP is required toobtain prior authorization from Aetna. Except forthose benefits described in the plan documents asdirect access benefits, plans with self-referral toparticipating providers (Aetna Open Access or AetnaChoice POS), plans that include benefits fornonparticipating provider services (Aetna Choice POSor QPOS), or in an emergency, you will need to obtaina referral authorization ("referral ") from your PCPbefore seeking covered nonemergency specialty orhospital care. Check your plan documents for details.Referral PolicyIf your plan documents state referrals are required,please review the following important points regardingreferrals.■ The referral is how your PCP arranges for you to becovered for necessary, appropriate specialty careand follow-up treatment.■■■■■■■You should discuss the referral with your PCP tounderstand what specialist services are beingrecommended and why.If the specialist recommends any additionaltreatments or tests that are covered benefits, youmay need to get another referral from your PCPprior to receiving the services. If you do not getanother referral for these services, you may beresponsible for payment.Except in emergencies, all hospital admissions andoutpatient surgery require a prior referral from yourPCP and prior authorization by Aetna.If it is not an emergency and you go to a doctor orfacility without a referral, you must pay the bill.Referrals are valid for one year as long as youremain an eligible member of the plan; the first visitmust be within 90 days of referral issue date.In plans without out-of-network benefits, coveragefor services from nonparticipating providers requiresprior authorization by Aetna in addition to a specialnonparticipating referral from the PCP. Whenproperly authorized, these services are fully covered,less the applicable cost-sharing.The referral provides that, except for applicable costsharing, you will not have to pay the charges forcovered benefits, as long as the individual seekingcare is a member at the time the services areprovided.Emergency CareIf you need emergency care, you are covered 24 hoursa day, 7 days a week, anywhere in the world. Anemergency medical condition is one manifesting itselfby acute symptoms of sufficient severity such that aprudent layperson, who possesses average knowledgeof health and medicine, could reasonably expect thewww.aetna.comXVII