Frequently asked questions

Find answers to commonly asked questions

To change your PCP, call Member Services at 1-855-300-5528 (TDD/TTY 711). Or go log into our secure member portal and select My Online Services to change PCPs.

Aetna Better Health of Kentucky will try its best to deal with your concerns or issues quickly and bring about a result that is acceptable. You may use our grievance process or our appeal process, depending on what kind of problem you have.

There will be no change in your services or the way you are treated by Aetna Better Health of Kentucky staff or a health care provider because you file a grievance or an appeal. We will maintain your privacy and give you any help you may need to file a grievance or appeal. This includes providing you with interpreter services or help if you have vision and/or hearing problems. You may also choose someone like a relative, friend or provider to act for you.

To file a grievance or to appeal a plan action, call 1‑855‑300‑5528 (TTY users dial 711, TDD users dial 1‑800‑627‑4702), or write to:

Aetna Better Health of Kentucky
Attn: Complaint and Appeal Department
9900 Corporate Campus Drive
Suite 1000
Louisville, KY 40223
Fax: 1-855-454-5585

When you contact us, you will need to give us your name, address, telephone number and the details of the problem.

Yes. Babies born to mothers enrolled in Aetna Better Health of Kentucky should be automatically enrolled in Aetna Better Health. Please call your local Department of Community Based Services and Aetna Better Health of Kentucky at 1-855-300-5528 (TTY users dial 711; TDD users dial 1-800-627-4702.

Copay is the amount of money a member has to pay when he/she receives a service from a health care provider. Aetna Better Health of Kentucky has reduced co‑pays for 2016. Please review the co‑pay schedule below, which has been updated for 2016.

How copays work

  • Your provider will ask you to pay a copay when you receive care.
  • The pharmacist will ask you to pay a copay when you get your medicine(s).

You will not have to pay copays:

  • For emergency services
  • If you are pregnant
  • If you are a non‑KCHIP (a child who is eligible for Medicaid through income or medical reasons) child under age 19
  • If you are a foster‑care child under age 19
  • For preventative services (Well Child Checkups, shots)
  • For family planning services
  • If you are in hospice care

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.

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

 

If you have questions or need additional help call Member Services. Our Member Services department is here for you. You can call us with questions at 1-855-300-5528 (TDD: 1-800-627-4702 or TTY: 711).

Emergency transportation: Call 911 or the closest ambulance service.

Non‑emergency transportation: Kentucky Medicaid will pay to take some members to get medical services covered by Kentucky Medicaid. If you need a ride, you must talk to the transportation broker in your county to schedule a trip.

Please note: KCHIP III children do not get non‑emergency transportation.

Each county in Kentucky has a transportation broker. You can only use the transportation broker for a ride if you cannot use your own car or do not have one. If you cannot use your car, you have to get a note for the transportation broker that explains why you cannot use your car. If you need a ride from a transportation broker and you or someone in your household has a car, you can:

  • Get a doctor’s note that says you cannot drive
  • Get a note from your mechanic if your car does not run
  • Get a note from the boss or school official if your car is needed for someone else’s work or school
  • Get a copy of the registration if your car is junked For a list of transportation brokers and their contact information, please visit www.chfs.ky.gov/dms/ or call Kentucky Medicaid at 1‑800‑635‑2570. For more information about transportation services, call the Kentucky Transportation Cabinet at 1‑888‑941‑7433.
  • The hours of operation are Monday through Friday, 8 a.m. to 4:30 p.m. ET and Saturday 8 a.m. to 1 p.m. ET. If you need a ride, you have to call 72 hours before the time that you need the ride. If you have to cancel an appointment, call your broker as soon as possible.

Kentucky Medicaid does not cover rides to pick up prescriptions.

You should always try to go to a medical facility that is close to you. But if you need medical care from someone outside your service area, you have to get a note from your PCP. The note has to say why it is important for you to travel outside your area. (Your area is your county and the counties next to it).

Referrals

Aetna Better Health of Kentucky does not require a referral from your PCP or OB/GYN before you see another Aetna Better Health provider unless you are a Lock‑In member. Your PCP is your medical home and should coordinate your care. You should call your PCP to tell him/her you are going to the other provider. We do not require a referral for members to see in‑network

doctors for routine and preventive health care services unless you are a Lock‑In member. Lock‑In members must have a referral to see any provider except the one that they are already assigned.

Prior authorization

Aetna Better Health of Kentucky must approve some health care services and supplies before you get them. This is called prior authorization.

Aetna Better Health follows nationally recognized guidelines for the care your provider suggests. These guidelines are used to make prior authorization decisions. Some services that need prior authorization are listed below. Your provider can get the full list of services that need prior

authorization. This list may change from time to time. Call Member Services at 1‑855‑300‑5528

(TTY users dial 711, TDD users dial 1‑800‑627‑4702), Monday through Friday, 7 a.m. to 7 p.m.

ET, to request the most current list.

Prior authorization list

Your provider must check if a prior authorization is required before providing you a service. Some items that require prior authorization are:

  • All inpatient services, including psychiatric, skilled nursing facilities and rehabilitation
  • All physical health services provided in the home
  • All services administered by providers not in our network (except an emergency; care for a child in foster care; and family planning)
  • Purchase of durable medical equipment, prosthetics, enterals and supplies costing more than $500
  • Durable medical equipment rentals
  • Dental anesthesia (in an outpatient facility)
  • Transplant services, including transplant evaluation
  • Some mental health and substance use services (not emergencies)
  • Metabolic foods
  • Some vision services
  • Some dental services
  • Chiropractic visits after the first 12
  • Radiology services (CT scans, MRIs, PET Scans)
  • Cardiology services
  • Most surgical procedures
  • Pain management services

*An Aetna Better Health of Kentucky network provider may not be in the transplant network. Please work with your Aetna Better Health transplant case manager to choose a provider.

2017 Schedule of Benefits

 

Service

Limits

Copay Amount

 

Hospital services

 

Acute inpatient hospital

 

$25

 

Inpatient Physician/Surgeon services

 

$0

 

Transplant

 

$0

 

Meals and lodging for appropriate escort of members

 

$0

 

Emergency services

 

Emergency room

 

$0

$8 Non‑ Emergency Use

 

Emergency ambulance

 

$0

 

Ambulatory services

 

Physician office visit

 

$0

 

Outpatient hospital

Does not cover cosmetic surgery (except for post‑ mastectomy re‑constructive surgery)

$0

 

Ambulatory surgical center

 

$0

 

Dental services (adult)

1 cleaning and 1 set of x‑rays per 12‑month period

$0

 

Dental services (child)

 

$0

 

Home health care

 

$0

 

Vision services

1 eye exam per year for adults

$0

 

Urgent care

 

$0

 

Radiation therapy

 

$0

 

Chemotherapy

 

$0

 

Family planning

 

$0

 

Podiatry

 

$0

 

Maternity services

 

Prenatal and postnatal care

 

$0

 

Delivery services

 

$0

 

Alternative birthing center services

 

$0

 

Home infusion therapy

Limited to administration by parent or guardian in the home

$0

 

2017 Schedule of Benefits

Service

Limits

Copay Amount

Prescription drugs

Home infusion therapy

Limited to administration by parent or guardian in the home

$0

Prescription Drugs

Non‑preferred brand copay is applicable to all members (including those typically excluded from copays)

  • Family planning, no copays
    • Tobacco cessation, no copays
    • 2nd Generation Antipsychotics and Injectable Antipsychotics,

$1 copay

  • Anticonvulsants, non‑ preferred bands, $4 copay
  • Oral oncology, non‑ preferred brands, $4 copay
    • Diabetic supplies
    • Meters, no copays
    • Test strips, control solutions, insulin needles, lancets, et

$4 copay with no more than one copay per calendar day being charged

$0 Generic

$0 Brand

$4 Non‑ Preferred brand

$0 Preferred brand

$4 Non Preferred

$0 Preferred Brand

$4 Non‑ Preferred brand

$0 Preferred brand

$4 Non‑ preferred brand

$0

$0

$0

Rehabilitative and Habilitative services and devices

Skilled Nursing and Rehabilitation

 

$0

Chiropractic Services

26 visits per calendar year

$3

Durable Medical Equipment

 

$0

Hearing Aids/Audiometric Services

Limited to children under 21

$0

Prosthetic Devices

 

$0

Physical / Occupational / Speech Therapy

20 visits per year per therapy (combined for rehabilitative and habilitative); no limit for children

$0

2017 Schedule of Benefits

Service

Limits

Copay Amount

Laboratory, Diagnostic and Radiology services

Laboratory and Diagnostic and Radiology services

 

$0

Pediatric services

Autism Spectrum Disorders

Up to Age 21

$0

EPSDT Special Services

Limited to medically necessary services not included in the State Plan and authorized under Section 1905(a) of the Social Security Act, or 42 USC Section 1396d(a)

$0

EPSDT Screening

 

$0

Commission for Children with Special Health Care Needs

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

$0

Specialized Children’s Services Clinics

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

$0

Targeted Case Management: Children with SED, Substance Use Disorders or co‑occurring mental health of substance use disorders and chronic or complex physical health issues.

 

$0

Mental Health and Substance Use Disorder services

Targeted Case Management: Individuals with Severe Mental Illness (SMI), Substance Use Disorders (SUD) or co‑occurring mental health or substance use disorders and chronic or

complex physical health issues.

 

$0

Inpatient Mental Health/Substance Use services

 

$0

Outpatient Mental Health/Substance Use services

 

$0

Crisis services

 

$0

Residential services or Substance Use Disorders

 

$0

Tobacco cessation

 

$0

Preventive services and Chronic Disease Management

Allergy services

 

$0

2017 Schedule of Benefits

Service

Limits

Copay Amount

Immunizations and other preventive health services

 

$0

Other

Long Term Care

Limited to individuals who meet level of care criteria for a nursing facility or an

Intermediate Care Facility for Individuals with Intellectual Disabilities

$0

Non‑Emergency  Transportation

 

$0

Hospice

 

$0

Renal Dialysis/Hemodialysis

 

$0