Covered Services
Services covered by Aetna Better Health are listed below. Some limitations and prior authorization requirements may apply. All services must be medically necessary.* If you have questions about covered services, call Member Services at 1-866-212-2851.
Type of Care |
Covered Services |
Coverage and Benefit Limitations |
Abortions |
Covered benefit when necessary to preserve the woman's life or health or when the pregnancy is the result of rape or incest. |
|
Ambulatory Surgery |
|
Covered benefit |
Behavioral Health |
Mental health services including but not limited to:
Subacute alcohol and substance abuse treatment, including but not limited to:
|
Covered benefit |
Chiropractic |
Services are limited to the treatment of the spine by manual manipulation. |
Covered benefit |
Dental |
|
Covered benefit. |
Dialysis — Outpatient |
Covered benefit |
|
Medical Equipment and Supplies |
Nondurable medical supplies, including, but not limited to:
Durable medical supplies (DME) including but not limited to:
|
Covered benefit Provider must get authorization for these services. The member must use a medical supply company or pharmacy that is in our network. |
Emergency Room |
Covered benefit |
|
Emergency Transportation |
Covered benefit |
|
Eye Care |
|
Covered benefit. Call March Vision Care toll free at 1-888-493-4070 or see vision page for more information. Limitations on exams and glasses:
|
Family Planning |
Including but not limited to:
|
Covered benefit. Limitations on sterilization include:
|
Hearing Care |
Includes:
|
Covered benefit. |
Home Health Care |
Covered benefit |
|
Hospice Services |
Covered benefit |
|
Hospital - Inpatient |
Covered benefit |
|
Immunizations (Shots) |
Covered benefit |
|
Laboratory Services/X-rays |
Covered benefit |
|
Nurse Midwife Services |
Covered benefit |
|
Maternity Care |
|
Covered benefit |
Nursing Care |
Members under the age of 21 can get medically necessary in-home shift nursing and personal care services provided by a registered nurse (RN), licensed practical nurse (LPN) or Certified Nurses Aide under the direction of a qualified home health agency. |
Covered benefit for members ages 19- 20 who are not in the Medically Fragile Technology Dependent (MFTD) waiver. Home health agency providing the nursing services must be in our network. |
Organ Transplant |
Covered benefit |
|
Orthotics/Prosthetics |
Covered benefit |
|
PCP visit |
Covered benefit |
|
Podiatric Services |
Covered benefit |
|
Provider Office Visits/Preventive Care |
Includes:
|
Covered benefit |
Rehabilitative Services |
Including but not limited to:
|
Covered benefit |
Radiology |
Covered benefit |
*Definition of medically necessary
Aetna Better Health considers a service, supply or medicine to be medically necessary when it meets the descriptions below.
- > It is appropriate.
- > It is considered by other health professionals to be good medical practice.
- > It meets Aetna Better Health's guidelines, policies and procedures.
- > It is used to diagnose or treat a covered illness or injury.
- > It is used to prevent an illness.
- > It is used to help you get well or stay well.
Non-Covered Services
The following services are not covered.
- Services available without charge.
- > Services prohibited by state or federal law.
- > Experimental procedures.
- > Research-oriented procedure.
- > Medical examinations required for entrance into adult educational or vocational programs.
- > Autopsy examinations.
- > Artificial insemination.
- > Medical or surgical procedures performed for cosmetic purposes.
- > Medical or surgical transsexual treatment services.
- > Diagnostic or therapeutic procedures related to secondary infertility/sterility.
- > Acupuncture.
- > Medical care provided by mail or telephone, except for approved telemedicine services. (Note: this does not prohibit the mailing of medically necessary covered items; for example, prescription drugs sent to a patient by a mail-order pharmacy.)
- > Services provided by terminated or barred providers.
- > Visits with persons other than a patient, such as family members or long term care facility staff.
- > Items or services for which medical necessity is not clearly established.
- > Services provided only, or primarily, for the convenience of patients or their families.
- > Services from a provider that is NOT in our network (unless approved by Aetna Better Health first).
- > Cosmetic services or items.
- > Any service not prior authorized that needs prior authorization.
- > Services or items given free of charge, or for which charges are not usually made.
- > Services that are determined to be experimental by the health plan medical director.
- > Sex change operations and reversal of voluntary sterilization.
- > Medications and supplies without a prescription.