Important info about your Aetna Better Health® of Oklahoma plan
Get to know your rights and responsibilities, quality and case management programs, accessing benefits and services like pharmacy, privacy info and more.
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Where to find important info about your plan
Your rights and responsibilities
How we make decisions about your health care (utilization management)
Where to find important info
Your Aetna Better Health member handbook covers everything you need to know about your health plan. You can find info on:
- Benefits and services that are covered, and those that are not
- How to get your medicine and other rules about pharmacy benefits
- Copayments and other expenses that may apply to you
- Benefit restrictions outside of the Aetna Better Health service area
- How to get language help
- How to submit a claim
- How to get info about providers in the Aetna Better Health network
- How to get primary care services
- How to get specialty care. This includes:
- Behavioral health care
- Hospital services
- Care for specific conditions
- How to get a referral
- How to get care after normal office hours
- How and when to use emergency room care
- How to get care outside of your service area
- How to file a complaint or grievance
- How to appeal a decision that affects your coverage, benefits or relationship with your plan
- How we make decisions about new technology we may include as a covered benefit
- How we make decisions about your care (called utilization management)
- Your member rights and responsibilities and a notice of privacy practices
The member handbook is updated every year. If there are major changes, we will send you a letter about it at least 30 days before the changes are effective.
You can view your handbook online at AetnaBetterHealth.com/oklahoma/member-materials-forms.html.
Prefer a hard copy? Call Member Services at 1-844-365-4385 (TTY: 711) to have one mailed to you. Let us know if you need it in another language, a larger font or other formats.
Get the most out of your benefits
Your rights and responsibilities
You have rights and responsibilities as an Aetna Better Health® of Oklahoma member. Be sure to check your materials and forms page for your member handbook. Inside, you’ll find your full rights and responsibilities.
Your rights
As a member of Aetna Better Health, you have a right to:
- Receive information on the SoonerSelect program and Aetna Better Health.
- Be treated with respect and with due consideration for your dignity and privacy.
- Receive information on available treatment options and alternatives, in a way you understand.
- Participate in decisions regarding your health care, including the right to refuse treatment.
- Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
- Request and receive a copy of your medical records, and to request that they be amended or corrected.
- Obtain available and accessible health care services covered by Aetna Better Health.
- A candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
- Voice complaints or appeals about Aetna Better Health and the care provided.
- Make recommendations regarding Aetna Better Health rights and responsibilities policy.
- File a grievance and appeal.
Your responsibilities
As a member of Aetna Better Health, you agree to the following responsibilities:
- Check OHCA and Aetna Better Health information, correct inaccuracies and allow government agencies, employers and providers to release records to OHCA or Aetna Better Health.
- Notify OHCA or Aetna Better Health within 10 days if there are changes in income, the number of people living in the home, address or mailbox changes, or health insurance changes.
- Transfer, assign, and authorize to OHCA all claims you may have against health insurance, liability insurance companies or other third parties. This includes payments for medical services made by OHCA for any dependents.
- Respond to requests from the Oklahoma Human Services (OHS) Office of Child Support Services.
- Allow SoonerCare to collect payments from anyone who is required to pay for medical care.
- Share necessary medical information with any insurance company, person or entity who is responsible for paying the bill.
- Inspect any medical records to see if claims for services can be paid.
- Obtain permission for Oklahoma Human Services or OHCA to make payment or overpayment decisions.
- Keep your identification card and know your Social Security number to receive health care services or prescriptions.
- Confirm that any care received is covered.
- Understand how and when to request non-emergency medical transportation (NEMT) services.
- Cost sharing.
- Ensure all information provided to OHCA or Aetna Better Health is complete and true upon penalty of fraud or perjury.
- Follow plans and instructions for care that you have already agreed to with your practitioners.
- Understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.
Go to AetnaBetterHealth.com/oklahoma/medicaid-rights-responsibilities.html for more info.
Your pharmacy benefits
Learn more about your pharmacy benefits at AetnaBetterHealth.com/oklahoma/pharmacy-prescription-drug-benefits.html. You can find info such as:
- Preferred drug list (PDL) or formulary
- Medications that require prior authorization and coverage criteria
- A list and explanation of medications that have limits or quotas
- Copayment and coinsurance requirements and the medications or classes to which they apply
- Steps for getting clinical or PDL prior authorization, generic substitution or preferred brand interchange
- Info on pharmaceutical management procedures
- Criteria used to add new medicines to the formulary
- How to ask for a coverage exception
How we make decisions about your health care
Our utilization management (UM) program ensures you get the right care in the right setting when you need it. UM staff can help you and your providers make decisions about your health care.
When we make decisions, it’s important for you to remember the following:
- We make UM decisions by looking at your benefits and clinical guidelines for the most appropriate care and service. We consider:
- Your needs
- Evidenced-based practice
- Availability of care
- You also must have active coverage.
- We don’t reward providers or other people for denying coverage or care.
- Our employees do not get any incentives to reduce the services you get.
If you have questions about UM, call Member Services. They can also help if you need language translation or support.
Get extra support for your health care needs
Every Aetna Better Health member is on their own health care journey. We can help guide you in managing and improving your health. Our population health management programs can help with things like:
- Managing a health condition
- Pregnancy care
- When to use urgent care
- What to do after a hospital stay
- Staying healthy and preventing health problems
You can learn more about our programs at AetnaBetterHealth.com/oklahoma or in your member handbook.
For most programs, we will automatically enroll you if you are eligible. You can choose to join or leave a program at any time by calling Member Services.
You can also get a referral to a management program. Referrals can come from:
- Your provider
- A medical management program
- Hospital discharge planner
- A caregiver
- Yourself
Call Member Services at 1-844-365-4385 (TTY: 711) or go to our website for a member referral into case management.
h2 id="privacy">We care about your privacy
We protect your personal health information (PHI). That includes your race, ethnicity, language, sexual orientation and social needs info. We only share your info when needed and as allowed by law.
You have rights over your health data. That includes how it’s used and who can access it. Go to AetnaBetterHealth.com/health-optimization-disclaimer.html to learn more about your privacy rights and how we safeguard your data.
Language assistance
Aetna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
Go to AetnaBetterHealth.com/oklahoma/notice-of-non-discrimination.html for more info.
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1-844-365-4385 (TTY: 711) သို့
