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All Aetna Better Health members, including LTSS, should have paperwork completed to help your providers know your health care wishes, if you should ever be unable to make those decisions for yourself. This paperwork is called advance directives. Take the time to complete advance directive forms, which can include a health care power of attorney and a living will. Return a copy of your completed forms to your case manager. If you have not yet completed this paperwork, your case manager will continue to talk about the importance of this form with you.

We never want to think about the end of life. But it's important for everyone to plan for it. Even if you are not sick or injured now, you should consider what kind of care you would want if you were. What if you were unable to express your wishes?

This is where advance directives can help. Advance directives are legal documents that tell your providers and family what you want for end-of-life care. You can still get health care if you do not have advance directives. This includes being admitted to a hospital or other facility.

There are several kinds of advance directives. They include:

Living will
A living will is a legal document that tells others your wishes for care that could keep you alive if you were in danger of dying. This care might include life support systems.

Health care power of attorney
A health care power of attorney is a document in which you choose a person to make health care decisions for you if you cannot make them for yourself. You must give this person permission in writing to make your health care decisions for you.

Mental health treatment preference declaration
A mental health treatment preference declaration lets you say if you want to receive electroconvulsive treatment (ECT) or psychotropic medicine when you have a mental illness and are unable to make these decisions for yourself. It also allows you to say whether you want to be admitted to a mental health facility for up to 17 days of treatment.

Do not resuscitate (DNR) orders
You can also ask your PCP to help you make a do not resuscitate, or DNR, order. A DNR order is an order for medical treatment that says cardiopulmonary resuscitation, or CPR, will not be used if your heart and/or breathing stops. If this is something you want, talk to your PCP about helping you with a DNR order.

If you do not have an advance directive, talk to your PCP. Or call Member Services at
1-866-212-7851 for information. To link to pdfs of the different advance directive forms, visit Illinois Department of Health Services advance directives.

We can give you information in another format or language. This includes enrollment materials. We have audio CD-ROM, large print or Braille. Our member materials are also available in Spanish. We offer language interpretation services, including sign language, as well as CART reporting for the hearing impaired at no cost to you. Call Member Services at 1-866-212-2851 for more information.

Aetna Better Health is committed to providing continuity of care for new members who are currently under treatment for acute and chronic health conditions. Our goal is to make sure that our transition process is efficient, timely and seamless with no disruption in care for these new members. During the initial transition period, we will make maximum effort to maintain the members with their current medical home/primary care provider (PCP) and continue courses of treatment with their specialty providers.

Our protocols support a collaborative relationship with non-participating providers for prior authorization of the existing course of treatment and attempt to have the provider join our network. We will honor all previous service prior authorizations for up to ninety (90) days following initial enrollment.

Our Member Services Department is open to answer your questions 24 hours a day, 7 days a week (except state holidays). Call us at 1-866-212-2851 with questions about your benefits or for help choosing a provider. We can also help solve problems getting health care service

A grievance is a complaint about any matter other than a denied, reduced or terminated service.

Aetna Better Health takes member grievances very seriously. We want to know what is wrong so we can make our services better. If you have a grievance about a provider or about the quality of care or services you have received, you should let us know right away. Aetna Better Health has special procedures in place to help members who file grievances. We will do our best to answer your questions or help to resolve your concern.

Filing a grievance will not affect your health care services or your benefits coverage.

These are examples of when you might want to file a grievance:

  • Your provider or an Aetna Better Health staff member did not respect your rights
  • You had trouble getting an appointment with your provider in an appropriate amount of time.
  • You were unhappy with the quality of care or treatment you received
  • Your provider or an Aetna Better Health staff member was rude to you
  • Your provider or an Aetna Better Health staff member was insensitive to your cultural needs or other special needs you may have

You can make your grievance on the phone or in writing. You can call Member Services for help at 1-866-212-2851. You can also send or fax a letter telling us about your grievance to:

Aetna Better Health
Attn: Grievance and Appeals Dept.
333 West Wacker Drive, Mail Stop F646
Chicago, IL 60606
Fax: 1-855-545-5196

An appeal is a way for you to ask for someone to review our actions. The list below includes examples of when you might want to file an appeal.

  • Not approving a service your provider asks for
  • Stopping a service that was approved before
  • Not paying for a service your PCP or other provider asked for
  • Not giving you the service in a timely manner
  • Not answering your appeal in a timely manner
  • Not approving a service for you because it was not in our network

If we decide that the requested service cannot be approved, or if a service is reduced, stopped or ended, you will get a "Notice of Action" letter from us. This letter will tell you the following:

  • What action was taken and the reason for it
  • Your right to file an appeal and how to do it
  • Your right to ask for a State Fair Hearing from the Department of Human Services and how to do it
  • Your right to ask for an expedited resolution and how to do it

Your right to ask to have benefits continue during your appeal, how to do it and when you may have to pay for the services

You must file your appeal within 30 calendar days from the date on the Notice of Action letter.

Here are two ways to file an appeal:

  • Call Member Services at 1-866-212-2851. If you do not speak English, we can provide an interpreter at no cost to you. If you are hearing impaired, call the Illinois Relay at 711.
  • Write to us at:

    Aetna Better Health
    Attn: Grievance and Appeals Dept
    333 West Wacker Drive, Mail Stop F646
    Chicago, IL 60606
    Fax: 1-855-545-5196

Someone can represent you when you file your appeal, such as a family member, friend or provider. You must agree to this in writing. Send us a letter telling us that you want someone else to represent you and file an appeal for you. Include your name, member ID number from your ID card, the name of the person you want to represent you and what action you are appealing. When we get the letter from you, the person you picked can represent you. If someone else files an appeal for you, you cannot file one yourself for that action.

You or your representative, including a provider acting with your written permission, may start an appeal within 30 calendar days from the date on our Notice of Action letter. But if you want your services to continue while your appeal is reviewed, you must file your appeal no later than 10 business days from the date on our Notice of Action letter. We can help you write your appeal, if needed.

What happens next

  • We will send you a letter within three business days saying we got your appeal. We will tell you if we need more information.
  • We will tell you how to give us more information in person or in writing, if needed.
  • You provide more information about your appeal, if needed.
  • You can see your appeal file.
  • You can be there when the Appeals Committee reviews your appeal.

The Appeals Committee will review your appeal. They will let you know if they need more information and will make a decision within 15 business days of receiving that information but no more than 30 calendar days. We will call you to tell you the decision. We will also send the results to you in writing. The decision letter will tell you what we will do and why.

A provider with the same or similar specialty as your treating provider will review your appeal. It will not be the same provider who made the original decision to deny, reduce or stop the medical service. The provider who reviews your appeal will not report to the provider who made the original decision about your case.

We can extend the time for making a decision about your grievance by up to 14 days. We may extend the time to get more information. If we do this, we will send you a letter explaining the delay.

You can also ask for an extension, if you need more time.

If the Appeals Committee's decision agrees with the Notice of Action, you may have to pay for the cost of the services you got during the review. If the Appeals Committee's decision does not agree with the Notice of Action, we will let the services start right away.

Learn more, including how to expedite your appeal, in your member handbook.

Service authorizations
These LTSS member services require prior authorization by the case manager or Prior Authorization departments and/or also physician’s orders.

Prior Authorization Guideline Chart

Caregivers must complete time sheets that accurately reflect the hours they have worked. Caregivers who fraudulently fill in time and their hiring agencies could be held liable for falsifying information.

Help stop fraud by taking the following steps:

  • Never sign a blank time sheet or a time sheet that is not completely filled in.
  • Never sign a time sheet if you know the caregiver did not work the time listed. This is fraud. If this happens, call the agency or your case manager to report this situation.
  • Never sign a time sheet if it is for dates you were in the hospital. Caregivers cannot provide you care or care for your house while you are in the hospital. This is fraud. In addition, caregivers cannot “make up” the time once you return from the hospital. This can be considered fraud. For example, if you needed bathing assistance five days a week and were in the hospital for four days, the caregiver cannot visit you on the fifth day and try to make up the time for the first four days.

We understand that during these difficult economic times it may be tempting to help caregivers get a full paycheck even if they haven’t provided all the care that they were assigned to provide. However, this is considered fraud and an abuse of the Medicaid health system.

Summer 2012 English / Spanish