Participant materials and benefits

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Participant Handbook. Limitations and restrictions may apply. For more information, call Aetna Better Health FIDA Plan Participant Services or read the Aetna Better Health FIDA Plan Participant Handbook. Benefits may change on January 1 of each year.

The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.

 

You can get this information for free in other languages. Call 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free.

Get to know your 2017 participant materials

Want to understand the details of your health plan? There are links to your Aetna Better Health FIDA Plan Participant Handbook and other documents below. Look them over carefully. These documents explain your health plan and tell you what is covered and what is not. You can get help finding a doctor and learn about our care management programs. You can also find information about how to file grievances and appeals.

Annual Notice of Change
English | Spanish | Russian | French-Creole | Italian | Korean |Chinese

Summary of Benefits 

English | Spanish | Russian | French-Creole | Italian | Korean |Chinese

Participant Handbook 

English | Spanish | Russian | French-Creole | Italian | Korean | Chinese 

List of Covered Drugs/Formulary 

English | Spanish | Russian | French-Creole | Italian | Korean |Chinese

Provider and Pharmacy Directory

Multi-Language Insert

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.

Keeping you well means helping prevent illnesses before they start or get worse. This means that we cover regular visits to the doctor, lab tests, X-rays and any other tests you need. Plus, we help with serious health concerns. These may be chronic illnesses 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’s not, and how you can find the right care when you need it.

Summary of Benefits
Your Summary of Benefits 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.

Dental

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 twice 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.

Nurse advice line

Help is a phone call away
Not sure if you should go to the emergency department or urgent care?  The Aetna Better Health FIDA Plan Nurse Line can help. For answers to your questions, call the 24-hour Nurse Advice Line at 1-855-494-9945 (TTY 711) and select the option for Nurse Advice Line. Our nurses are here for you 24 hours a day, 7 days a week.

Behavioral health

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 or a mood disorder, we cover any therapy or medicine you need. We can also help you if you have an alcohol or drug problem. Behavioral health benefits cover these services.

Below is a partial list of what your plan covers for mental health. For a complete list, view your Summary of Benefits.

  • Mental health assessments
  • Medicines
  • Counseling
  • Group therapy
  • Partial hospitalization
  • Alcohol and drug detoxification
  • Community support
  • Lab services for urine screens
  • Methadone administration

When you need help right away
You have 24-hour access to help in a crisis. Just call Participant Services at 1-855-494-9945 (toll-free); TTY NY Relay 7-1-1. The line is open 24 hours a day, 7 days a week.

Vision

See better --Your plan covers eye exams
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.

Transportation

If you have an emergency and have no way to get to the hospital, call 911 for an ambulance.

Aetna Better Health FIDA Plan covers ambulance rides in a medical emergency for all members.

To find out more about getting a ride to your doctor visits, call Medical Transportation Management (MTM) at 1-844-239-5969.

You need to make your transportation appointments three days in advance. When you call to schedule your ride, make sure we have all the information from you. That includes:

  • Name of the doctor
  • Address
  • Telephone
  • Time of appointment
  • Type of transportation needed (e.g., regular car, wheelchair-accessible van)

Over-the-counter medications You are eligible for a monthly benefit of $50 in over-the-counter (OTC) supplies. This benefit, which is for Aetna Better Health FIDA Plan participants only, allows you to get some OTC catalog supplies delivered to your home (up to $50). You find the order form here. For more information, talk to your care manager or call Participant Services at 1-855-494-9945 (TTY 711), 24 hours a day, 7 days a week

Download the 2017 OTC form.

How to get care from out-of-network providers

If you need care that our plan covers and our network providers cannot give it to you, you can get permission from Aetna Better Health FIDA Plan or your IDT to get the care from an out-of-network provider. In this situation, we will cover the care as if you got it from a network provider and at no cost to you. In order for the care to be covered, the out-of-network provider must contact us for prior authorization before you get the care.

Remember, when you first join the plan, you can continue seeing the providers you see now during the “transition period.” In most cases, the transition period will last for 90 days or until your Person-Centered Service Plan is finalized and implemented, whichever is later. During the transition period, our Care Manager will contact you to help you find and switch to providers that are in our network. After the transition period, we will no longer pay for your care if you continue to see out-of-network providers, unless Aetna Better Health FIDA Plan or your IDT has authorized you to continue to see the out-of-network provider.

— Please note: If you need to go to an out-of-network provider, please work with Aetna Better Health FIDA Plan or your IDT to get approval to see an out-of-network provider and to find one that meets applicable Medicare or Medicaid requirements. If you go to an out-of-network provider without first getting Plan or IDT approval, you may have to pay the full cost of the services you get.

What if a network provider leaves our plan?

A network provider you are using might leave our plan. If one of your providers does leave our plan, you have certain rights and protections that are summarized below:

• Even though our network of providers may change during the year, we must give you uninterrupted access to qualified providers.

• When possible, we will give you at least 15 days’ notice so that you have time to select a new provider.

• We will help you select a new qualified provider to continue managing your health care needs.

• If you are undergoing medical treatment, you have the right to request, and we will work with you to ensure, that the medically necessary treatment you are receiving is not interrupted.

• If you believe we have not replaced your previous provider with a qualified provider or that your care is not being appropriately managed, you have the right to file an appeal of our decision.

If you find out one of your providers is leaving our plan, please contact us so we can assist you in finding a new provider and managing your care. Call Participant Services at 1‑855‑494‑9945 (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 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 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 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 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 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 September 28, 2016.

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

Aetna Better Health FIDA Plan covers screening for HBV infection, when ordered by the beneficiary's primary care physician or practitioner within the context of a primary care setting, and performed by an eligible Medicare provider for these services, within the context of a primary care setting with the appropriate U.S. Food and Drug Administration (FDA) approved/cleared laboratory tests, used consistent with FDA approved labeling and in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations, for beneficiaries who meet either certain conditions.

 

This summarizes CMS transmittal 195NCD / R197NCD.

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