[PDF] Directory - Aetna Medicare

absence of immediate medical attention to result inserious jeopardy to the person's health, or withrespect to a pregnant woman, the health of thewoman and her unborn child.Whether you are in or out of an Aetna GoldenMedicare plan service area, we simply ask that youfollow the guidelines below when you believe youneed emergency care.■ Call the local emergency hotline (ex. 911) or go tothe nearest emergency facility. If a delay would notbe detrimental to your health, call your PCP. Notifyyour PCP as soon as possible after receivingtreatment.■ If you are admitted to an inpatient facility, you or afamily member or friend on your behalf shouldnotify your PCP or Aetna as soon as possible.What to Do Outside Your Aetna GoldenMedicare Plan Service AreaIf you are traveling outside of your Aetna GoldenMedicare Plan service area, you are covered foremergency and urgently needed care. Urgent caremay be obtained from a private practice physician, awalk-in clinic, an urgent care center or an emergencyfacility.Certain conditions, such as severe vomiting, earaches,sore throats or fever, are considered “urgent care"outside your Aetna Golden Medicare Plan service areaand are covered in any of the above settings.If, after reviewing information submitted to us by theprovider that supplied care, the nature of the urgentor emergency problem does not qualify for coverage,it may be necessary to provide us with additionalinformation. We will send you an Emergency RoomNotification Report to complete, or a Member Servicesrepresentative can take this information by telephone.Follow-up Care after EmergenciesAll follow-up care should be coordinated by your PCP.Follow-up care with nonparticipating providers is onlycovered with a referral from your PCP (when requiredby your plan) or prior authorization from Aetna.Whether you were treated inside or outside yourAetna Golden Medicare Plan service area, if your planrequires referrals, you must obtain a referral beforeany follow-up care can be covered. If your plan doesnot require referrals you should contact Aetna at thenumber on your ID card before care is received at nonnetworkfacilities. Suture removal, cast removal, X-raysand clinic and emergency room revisits are someexamples of follow-up care.After-Hours CareYou may call your doctor’s office 24 hours a day, 7days a week if you have medical questions orconcerns. You may also consider visiting participatingUrgent Care facilities.How Aetna Compensates Your HealthCare ProviderAll the physicians are independent practicingphysicians that are neither employed nor exclusivelycontracted with Aetna. Individual physicians and otherproviders are in the network by either directlycontracting with Aetna and/or affiliating with a groupor organization that contract with us.Participating providers in our network arecompensated in various ways:■ Per individual service or case (fee for service atcontracted rates).■ Per hospital day (per diem contracted rates).■ Capitation (a prepaid amount per member, permonth).■ Through Integrated Delivery Systems (IDS),Independent Practice Associations (IPA), PhysicianHospital Organizations (PHO), Physician MedicalGroups (PMG), behavioral health organizations andsimilar provider organizations or groups. Aetna paysthese organizations, which in turn may reimbursethe physician, provider organization or facilitydirectly or indirectly for covered services. In sucharrangements, the group or organization has afinancial incentive to control the cost of care.One of the purposes of managed care is to managethe cost of health care. Incentives in compensationarrangements with physicians and health careproviders are one method by which Aetna attempts toachieve this goal.XVIII