Benefits & Services

Benefits Overview

We manage your covered benefits by:

  • ›Working with your provider to decide what care is needed
  • ›Deciding what care is covered

The health care provider you choose is your first point of contact for health care. This is the person you should call for most of your health care needs.

We contract with a select network of providers for your care. We check our providers and hospitals often to make sure you get the care you deserve. There may be times when you can’t get the care you need from an in-network provider. If this happens, you may need to go out of the network for the care. We must approve this first.

We only cover care or supplies that are medically needed. We decide medical need by looking at the accepted standards of care. We decide whether the care meets these standards.

Questions on out-of-network benefits? Just call Member Services at 1-855-300-5528 (TTY 711) for more information.

Also, read your Member Handbook. You’ll learn more about what benefits are covered. 

 

Aetna Better Health of Kentucky covers certain dental services for adults and children under the age of 21. Children living in Kentucky must get a dental exam before they start kindergarten.

Aetna Better Health contracts with Avesis to provide dental, oral surgery or orthodontic services for our members. Call Member Services at 1‑855‑300‑5528 (TTY 711), Monday through Friday, 7 a.m. to 7 p.m. ET, to find out how to get care. You may also look in your Provider Directory or under Find a Provider.

If you are a smoker, have a history of smoking, or use other types of tobacco, we want to work with you to help you stop. Aetna Better Health of Kentucky has a program that is designed to help you if you are ready to quit smoking. This service is provided over the phone. You can get help in the form of patches, gum or medications. If you would like assistance with smoking cessation please call 1‑855‑300‑5528 (TTY 711), Monday through Friday, 7 a.m. to 7 p.m. ET. And ask for Case Management.

The Commonwealth of Kentucky also has a free program. Always talk to your doctor before starting any new program. For more information on this free program, call THE QUIT LINE at 1‑800‑QUIT‑NOW (1‑800‑784‑8669).

Aetna Better Health of Kentucky covers certain vision services for adults and children under the age of 21. Children living in Kentucky must get an eye exam before they start kindergarten. Eyeglasses are limited to members under 21 years of age. Aetna Better Health contracts with Avesis to provide vision and eye care services for our members. 

Call Member Services at 1‑855‑300‑5528 (TTY 711), Monday through Friday, 7 a.m. to 7 p.m. ET, to find out how to get care. You may also look in your Provider Directory or under Find a Provider.

Aetna Better Health of Kentucky contracts with EviCore to provider radiology benefit management for our members. It is necessary for your provider to get prior authorization from EviCore to perform the following outpatient non‑emergency diagnostic tests:

  • MRI
  • PET
  • CT
  • CCTA
  • Stress Echo
  • Nuclear Cardiology
  • MUGA

How do you get your medicine?
Go to a network drug store and give them your prescription. Show your Aetna Better Health of Kentucky Member ID card and Kentucky Medicaid ID card. If you have Medicare or other insurance, you must show that ID card, as well. You may call Member Services at 1‑855‑300‑5528 (TTY 711), Monday through Friday, 7 a.m. to 7 p.m. ET, to get a drug list or a list of network drug stores.

We cover medicines on our preferred drug list
Aetna Better Health of Kentucky covers the medicines included on our Preferred Drug List. This is the list of drugs that we cover when they are medically necessary. This list was included in your welcome packet. Aetna Better Health does not pay for drugs that have not been approved by the Federal Drug Administration (FDA).

Some medicines need to be approved ‑ prior authorization
Aetna Better Health of Kentucky must approve some medicines on our drug list before we cover them. We do this through prior authorization or Step Therapy.

Step Therapy (ST)
Some drugs are not approved unless another drug has been tried first. ST coverage requires that a trial of another drug be used before a requested drug is covered.

When you get a new prescription, ask your provider if we need to approve the medicine before you can get it. If we do, ask if there is another medicine you can use that does not need approval. When we need to approve your medicine, your provider must contact Aetna Better Health of Kentucky for you. We will review the request to approve your medicine. If the pharmacist cannot reach Aetna Better Health to make sure it is approved, your pharmacist can give you a three day temporary supply of the new prescription.

We will tell you in writing if we do not approve the request. We will also tell you how to start the complaint/appeal process.

Quantity limits
Some drugs have limits to the number of doses you may get. This is called a quantity limit. The Food and Drug Administration (FDA) decides safe dose limits. For a partial list ofthe services we cover and to see what approvals are required you can call Aetna Better Health’s Member Services at 1‑855‑300‑5528.

The pharmacist will fill your prescription according to FDA safe dosing limits. He/she will do this even if your provider wrote the prescription for more than the recommended FDA safe dosing limits. The pharmacist will not give you more medicine if your provider does not get it prior authorized. The pharmacist will ask your provider to call us first.

Medical exceptions
If your medicine is not on our drug list, ask your provider if there is one on the drug list you can use. If not, your provider must ask us for a medical exception. We will decide after review and if necessary, after talking with your provider, if the drug on the drug list will not work for your medical condition. If your provider does not ask for the exception, Aetna Better Health of Kentucky may not pay for it.

We will review the medical exception request within 24 hours. If we are unable to meet this deadline, the pharmacist can give you a three day supply of the drug. If we do not approve your medical exception, we will tell you in writing. We will also tell you how to start the complaint process.

Brand‑name drugs instead of generic alternatives
Generic drugs are as good as brand‑name medicines. Aetna Better Health of Kentucky pays for generic drugs when available. If your provider wants you to have a brand‑name drug, he/she must ask Aetna Better Health for a prior authorization. We will review the request. If we do not approve the request for a brand‑name drug, we will tell you in writing. We will also tell you how to start the complaint process.

Medicines are not on our drug list when enrolled
If your drugs are not on our drug list when you are enrolled with Aetna Better Health of Kentucky, you may take your medicine for 30 days after you enroll with us. Your provider should change your medicine to one on our preferred drug list or ask for a medical exception. If we do not prior authorize the exception, we will tell you in writing. We will also tell you how to start the complaint process.

Family planning services includes birth control counseling and supplies. Aetna Better Health of Kentucky covers family planning for members of child‑bearing age. You do not need to ask your PCP before getting this care. Any care you receive is kept private. If you do not want to talk to your PCP about family planning, call Member Services at 1‑855‑300‑5528 (TTY 711), Monday through Friday, 7 a.m. to 7 p.m. ET. We can help you choose a family planning provider. You may get family planning services and supplies from an Aetna Better Health provider or a provider not in our network.

Behavioral health care are services to treat a member’s mental health. This includes alcohol and substance abuse. Covered services include:

  • Community Mental Health Center services
  • Inpatient mental health services
  • Outpatient mental health services
  • Psychiatric residential treatment facilities
  • Court‑ordered involuntary commitment for acute inpatient psychiatric services for members under age 21 and over age 65

If you need behavioral health services, your PCP may send you for care. In the case of a behavioral health emergency, you should call the Behavioral Health Crisis Hotline at 1‑888‑604‑6106 (TTY dial 711, TDD dial 1‑866‑200‑3269). It is open 24 hours a day, seven days a week, and 365 days a year. They can help you get the care you need.

Some behavioral health care is covered only when it has been pre‑authorized (unless it is an emergency). Please make sure your provider checks the prior authorization list before providing you behavioral health service. Inpatient care you get is reviewed during your stay. Your care will be covered as long as it is medically needed. If it is decided that all or part of your stay is not needed, the provider will be told that coverage will end.

Copay

Copay is the amount of money a member has to pay when he/she receives a service from a health care provider. Please see Benefits Grid starting on page 29 for copay amounts.

Limits on Copays

There is a limit on the total amount of copays you will have to pay. You will not have to pay more than 5% of your family’s income each quarter of the year. The first quarter of the year is January through March, the second quarter is April through June, the third quarter is July through September, and the fourth quarter is October through December.

We keep track of the copays you pay. When you reach the limit, you will not have to pay any more copays for the remainder of the quarter. If you pay a copay after your family has reached the maximum out-of-pocket amount, your provider will refund the copay to you.

If you have Medicare and Medicare pays for the service, you have no Medicaid copay.

Copayment Exceptions

All Medicaid members are required to pay the copays outlined below except for the following exempt individuals and services:

  • Foster children
  • Children enrolled in Medicaid
  • Pregnant women (includes 60-day period after pregnancy ends)
  • Kentucky Medicaid beneficiaries who have reached their cost sharing limit for the quarter (5% of the family’s total income per quarter)
  • Individuals receiving hospice care
  • Emergency services
  • Some family planning services
  • Preventive services

What are my Benefits?

The following is an overview of services that we cover and the copayments that may apply. Copayments, also called Copays, refer to the dollar amount you, as the member, may be responsible for paying when you receive certain services such as office visits, supplies, or prescriptions.

 

Benefit

Copay

Limits

Inpatient Medical Hospitalization

 

 

Acute Inpatient Hospital Services

$50

Per admission

Inpatient Physician/Surgeon Services

$0

Cosmetic surgery is not covered (except for post-mastectomy re-constructive surgery)

Transplant

$0

No limit

Emergency Services

 

 

Emergency Room (ER)

$0; $8

$8 for non-emergency use of the ER

Emergency Ambulance (ground or air)

$0

No limit

Ambulatory Patient Services

 

 

Physician Office Services

$3

No limit

 

Outpatient Hospital/ Ambulatory Surgical Center

$4

Cosmetic surgery is not covered (except for post-mastectomy re-constructive surgery)

Rural Health Clinic (RHC), Federally Qualified Health Center (FQHC) & Primary Care Center (PCC)

$3

Per visit

Dental Services (adults)

$3

$0 for children

Per visit

Home Health Care

$0

No limit

Vision Services (adults)

$3

1 eye exam per year

Vision Services (children)

$0

1 eye exam per year

Urgent Care

$3

Per visit

Radiation Therapy

$0

No limit

Chemotherapy

$0

No limit

Family Planning

$0

No limit

Podiatry

$3

No limit

Maternity and Newborn Care

 

 

Prenatal and Postnatal Care

$0

No limit

Maternity Services

$0

No limit

Prescription Drugs

 

 

Prescription Drugs

$1 Generic;

$4 Brand Name – no generic

No limit

Rehabilitative and Habilitative Services and Devices

Skilled Nursing and Rehabilitation

$0

No limit

Chiropractic Services

$3

Per visit

26 visits per 12-month period

Durable Medical Equipment

$4

Per item

Hearing Aids/Audiometric Services

$0

Limited to children under 21

Orthotic/Prosthetic Devices

$4

Per item

Physical / Occupational / Speech Therapy

$3

Per visit; 20 visits per therapy per year; No copay for children

Private Duty Nursing

$0

2,000 hours per year (outpatient only)

Laboratory, Diagnostic and Radiology Services

Laboratory, Diagnostic, and Radiology Services (outpatient)

$3

Per visit Per service

Pediatric Services

 

 

Autism Spectrum Disorders

$0

Up to Age 21

Early Periodic Screening, Diagnosis and Treatment (EPSDT) Special Services

$0

Limited to medically necessary services and must be prior authorized

Commission for Children with Special Health Care Needs

$0

Limited to children who meet the eligibility criteria of the Kentucky Commission for Children with Special Health Care Needs

Specialized Children’s Services Clinics

$0

Services limited to children under age 18 and must be performed by specialized clinics

Targeted Case Management: Severe emotional disability (SED) Children

$0

Limited to children who meet Kentucky’s statutory definition of SED

 

 

 

First Steps Services

$0

Services are available to children from birth

through age two who have developmental delays or diagnosed physical or mental conditions associated with

developmental delay.

Mental Health and Substance Use Disorder Services

Targeted Case Management

$0

No limit

Inpatient Mental Health/ Substance Use Services

$50

Per Admission

Outpatient Mental Health/ Substance Use Services

$3

Per visit

Psychiatric residential treatment facilities (PRTFs)

$0

Services for residents ages 6 to 21

Preventive Services and Chronic Disease Management

Smoking/Tobacco Cessation

$0

No limit

Allergy Services

$0

No limit

Wellness services (Immunizations and other preventive health services such as annual check-ups, pap smears, blood pressure screenings, etc.)

$0

No limit

Other

Non-Emergency Transportation

$0

No limit

Family Planning

$0

No limit

Hospice

$0

No limit

Second Opinion

$0

No limit

TeleHealth

$0

No limit

Renal Dialysis/Hemodialysis (outpatient)

$0

No limit

NOTES:

  • All benefits provided must be medically necessary.
  • Copays apply to all members unless exempt.
  • Copays are limited to no more than 5% of your family’s total income each calendar quarter (every 3 months)