Member Benefits

Understand your benefits

Coverage from head to toe

Looking to live a healthier life? Our benefits and programs are designed to help you do just that.

This coverage includes preventive services like doctor’s visits, lab testing, X-rays and more. Plus, we can help with serious health concerns. These may be chronic diseases or mental health issues. We also can connect you with resources in your community for extra help.

Look at this section closely so that you can better understand your plan. You’ll know what is covered, what is not, and how you can find the right care when you need it.

Summary of Benefits

Your Summary of Benefits and Coverage helps you understand how your health plan works. It provides details about the kind of care you can access, what services are covered and much more.

View your Summary of Benefits - English / Spanish

Care for your teeth

As an adult, you only get one set of teeth. It’s important to take care of your teeth and gums. That means brushing and flossing daily and seeing a dentist two times a year. Preventive care can help make sure small problems don’t become big ones.

For a complete list of what’s included in your dental coverage, view your Summary of Benefits - English / Spanish

Your mental health is important

We believe in total health. And your mental health is as important as your physical health. If you suffer from mental illness, mood disorder, or alcohol or drug problems, you may need therapy or medicine. Behavioral health benefits cover these services.

Your plan covers many kinds of services for mental health. Below is a partial list of what is covered. For a more complete list, view your Summary of Benefits - English / Spanish

Medicine for mental health

  • Mental health assessments
  • Counseling
  • Group therapy
  • 24-hour access to help for a crisis
  • Partial hospitalization
  • Alcohol and drug detoxification
  • Community support
  • Lab services for urine screens
  • Methadone administration

If you are in crisis, we can help. Call Member Services at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week.

See better with vision coverage

As you get older, you may notice changes in your eyes. Some of these changes are normal. Others are not. Preventive care is important at every age. Your vision coverage helps make sure that you get this care and that any problems are treated right away.

For a complete list of what’s included in your vision coverage, view your Summary of Benefits - English / Spanish

No car? No bus line? No problem

Don’t let a lack of transportation keep you from getting the care you need. If you don’t have a way to get to your doctor, we may be able to help. Aetna Better Health Premier Plan MMAI can connect you with free transportation services. We can arrange a ride for you and one other person, such as a caregiver.

For more information, call Member Services at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week.

National Coverage Determination Member Notification

The Centers for Medicare & Medicaid Services (CMS) sometimes change the coverage rules that apply to an item or service covered under Medicare and through your health plan that provides Medicare benefits. When these rules are changed, CMS issues a National Coverage Determination (NCD) and we are required to notify you of this information.

An NCD tells us:

  • What rule is changing
  • If Medicare will pay for an item or service
  • What item or service is covered

What does this mean to me?

We want you to be aware of any new NCDs that may affect your coverage. But new rules do not affect all members.

CMS has issued NCDs that apply to the following items/services:

This affects services given on or after August 7, 2019

 

Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD’s) that affect coverage for treatment. The recent NCD changes are as follows:

Effective for claims with dates of service on and after August 7, 2019.

 

CMS will cover autologous treatment for cancer with T-cells expressing at least one CAR when administered at healthcare facilities enrolled in the FDA Risk Evaluation and Mitigation Strategies (REMS) and meets specified FDA conditions.

 

If you think you qualify, speak with your physician.

 

This summarizes CMS transmittal R10454NCD

This affects services given on or after January 21, 2020

Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD’s) that affect coverage for treatment. The recent NCD changes are as follows:

  • CMS will cover acupuncture for chronic low back pain (cLBP) effective for claims with dates of service on and after January 21, 2020.

This NCD expands coverage for acupuncture services specifically targeted for chronic low back pain. Medicare determined it will cover acupuncture for cLBP up to 12 visits in 90 days. These services will only be covered by Medicare if cLBP:

  • lasts 12 weeks or longer
  • nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc.
  • disease);
  • not associated with surgery; and
  • not associated with pregnancy 

If you think you qualify, speak with your physician.

This summarizes CMS transmittal R10128NCD

This affects services given on or after March 16, 2018

The Centers for Medicare & Medicaid Services (CMS) reviewed the evidence for laboratory diagnostic tests using NGS in patients with cancer. They determined that some tests could improve health outcomes for Medicare beneficiaries with advanced cancer. Testing will be covered for beneficiaries with:

  • recurrent, relapsed, refractory or metastatic cancer
  • advanced stages III or IV cancer if the beneficiary either:
    • has not been previously tested using the same NGS test for the same primary diagnosis of cancer or
    • will get repeat testing using the same NGS test only when the treating physician gives a new primary cancer diagnosis and there will be further cancer treatment (e.g., therapeutic chemotherapy) 

The test must be ordered by the treating physician, performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, and have all of the following requirements met:

  • Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and,
  • an FDA-approved or -cleared indication for use in that patient’s cancer; and,
  • results provided to the treating physician for management of the patient using a report template to specify treatment options

This summarizes CMS transmittal R210NCD

This affects services given on or after April 10, 2018

Medicare will allow for coverage of MRI for beneficiaries under certain conditions with any of the following: implanted pacemaker, implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), or cardiac resynchronization therapy defibrillator (CRT-D).

If you think you qualify, speak with your physician.

This summarizes CMS transmittal R208NCD

This affects services given on or after December 7, 2017.

 

Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD’s) that affect coverage for treatment done as part of special studies (Coverage with Evidence Development/CED, Medicare approved studies).  These changes only apply to members involved in the special studies.  The recent NCD changes are as follows:

  • You are having surgery on your lower spine where the surgeon uses a very small incision and surgery is guided with imaging (x-ray) assistance (often referred to as “Percutaneous Image-guided Lumbar Decompression”/PILD)
  • You have a condition where the open spaces of your spine are narrowed and this puts pressure on your spinal cord or nerves (“Lumbar Spinal Stenosis”) and you have not had relief with non-surgical treatments.
  • You meet all the other specified conditions of the Medicare approved study.

These services will only be covered by Medicare if they are provided in a Medicare-approved clinical study under Coverage with Evidence Development (CED.)

If you think you qualify, speak with your physician.

This summarizes CMS transmittal R196NCD.

This affects services given on or after April 3, 2017.

Local Medicare administrators will decide if they'll cover topical oxygen for the treatment of chronic non-healing wounds.

This summarizes CMS transmittal R203NCD.

This affects services given on or after January 18, 2017

Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD’s) that affect coverage for treatment done as part of special studies (Coverage with Evidence Development/CED, Medicare approved studies). These changes only apply to members involved in the special studies. The recent NCD changes are as follows:

Medicare will cover placement of a “leadless pacemaker” if you are enrolled in a special approved clinical study. A leadless pacemaker is placed without the need for a device pocket and insertion of a pacing lead which are parts of traditional pacing systems. You should speak with your doctor if you think you qualify to be a participant in an approved clinical study to receive this device.”

This summarizes CMS transmittal R201NCD

This affects services given on or after August 30, 2016

Centers for Medicare and Medicaid Services (CMS) recently released a notice in response to public questions around gender reassignment surgeries. This notice restates that there are no national CMS coverage guidelines for this service. Coverage decisions for this type of surgery are made by your local Plan, according to your benefits and your Plan’s medical necessity guidelines. If you have any questions about your coverage for this type of surgery, please contact Member Services at number on your Member ID.

This summarizes CMS transmittal R194NCD

This affects services given on or after February 8, 2016

Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD’s) that affect coverage for treatment done as part of special studies (Coverage with Evidence Development/CED, Medicare approved studies).  These changes only apply to members involved in the special studies.  The recent NCD changes are as follows:

  • Coverage will be approved for a special heart procedure (Left Atrial Appendage Closure, LAAC, if the device planned for use has FDA approval; and
  • You have a specific type of irregular heart beat (Non-Valvular Atrial Fibrillation, NVAF; and

You meet all the other specified conditions of the Medicare approved study. These services will only be covered by Medicare if they are provided in a Medicare-approved clinical study under Coverage with Evidence Development (CED.)

If you think you qualify, speak with your physician.

This summarizes CMS transmittal R192NCD

This affects services given on or after January 27, 2016

Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD’s) that affect coverage for treatment done as part of special studies (Coverage with Evidence Development/CED, Medicare approved studies).  These changes only apply to members involved in the special studies.  The recent NCD changes are as follows:

  • Expanded coverage for donor stem cell transplant (allogenic hematopoietic stem cell transplant) for sickle cell disease, certain diseases of the blood cells (myelofibrosis, multiple myeloma), other rare diseases. In a donor stem cell transplant, a doctor takes part of a healthy donor’s stem cell or bone marrow. This is then specially prepared and given to a patient through a tube in a vein (intravenous infusion). The patient also receives high dose chemotherapy (such as certain cancer drugs) and/or radiation treatments before getting this transplant through the vein.

This NCD expands coverage for donor HSCT items and services. These services will only be covered by Medicare if they are provided in a Medicare-approved clinical study under Coverage with Evidence Development (CED.). When bone marrow or peripheral blood stem cell transplantation is covered, all required steps are included in coverage.  If you think you qualify, speak with your physician.

This summarizes CMS transmittal R191NCD

This affects services given on or after October 9, 2014

Cologuard is a test that is performed on a stool sample to check for colon cancer. You no longer need authorization from your health plan before you have this test done.

This summarizes CMS transmittal R183NCD

This is effective for services on or after May 25, 2017.

The Centers for Medicare and Medicaid Services (CMS) issued an NCD to cover SET for beneficiaries with intermittent claudication (IC) for the treatment of symptomatic PAD.

SET involves the use of intermittent walking exercise, which alternates periods of walking to moderate-to-maximum claudication, with rest. SET has been recommended as the initial treatment for patients suffering from IC, the most common symptom experienced by people with PAD.

The SET program must:

  • Consist of sessions lasting 30-60 minutes, comprising a therapeutic exercise-training program for PAD in patients with claudication
  • Be conducted in a hospital outpatient setting, or a physician’s office
  • Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD
  • Be under the direct supervision of a physician (as defined in Section 1861(r)(1)) of the Social Security Act (the Act), physician assistant, or nurse practitioner/clinical nurse specialist (as identified in Section 1861(aa)(5) of the Act)) who must be trained in both basic and advanced life support techniques.

This summarizes CMS transmittal R206NCD.