HMO SNP

Aetna Better Health of Virginia (HMO SNP) is available to people who have Medicare and who receive Medicaid assistance from the Commonwealth Coordinated Care Plus (Medicaid) and Dual Eligible Special Needs Plan (Medicare). Aetna Better Health of Virginia (HMO SNP) is a Medicare Special Needs Plan, which means our plan benefits and services are designed for people with special health care needs. Our plan offers additional benefits and services not covered under Medicare, such as dental, hearing aids, and eyewear. If you are a member of Aetna Better Health and enroll in the Aetna Better Health of Virginia (HMO SNP) we will coordinate your Medicare and Medicaid covered services for you. 

To speak to someone for help with a complaint or information request, call 1-800-Medicare, or visit online.

Service Area

Although Medicare is a Federal program, Aetna Better Health of Virginia (HMO SNP) is available only to individuals who live in our plan service area. To remain a member of our plan, you must continue to reside in the plan service area. The service area is all regions and all counties in the Commonwealth of Virginia.

Our service area includes these counties in the Commonwealth of Virginia:

Accomack 
Albemarle 
Alleghany 
Amelia 
Amherst 
Appomattox 
Arlington 
Augusta 
Bath 
Bedford 
Bland 
Botetourt 
Brunswick 
Buchanan 
Buckingham 
Campbell 
Caroline 
Carroll 
Charles City 
Charlotte 
Chesterfield 
Clarke 
Craig 
Culpeper
Cumberland 
Dickenson 
Dinwiddie 
Essex 
Fairfax 
Fauquier 
Floyd 
Fluvanna 
Franklin 
Frederick 
Giles 
Gloucester 
Goochland 
Grayson 
Greene 
Greensville 
Halifax 
Hanover 
Henrico 
Henry 
Highland 
Isle of Wight
James City 
King and Queen

King George 
King William 
Lancaster 
Lee 
Loudoun 
Louisa 
Lunenburg 
Madison 
Mathews 
Mecklenburg 
Middlesex 
Montgomery 
Nelson 
New Kent 
Northampton 
Northumberland 
Nottoway 
Orange 
Page 
Patrick 
Pittsylvania 
Powhatan 
Prince Edward 
Prince George
Prince William 
Pulaski 
Rappahannock 
Richmond 
Roanoke 
Rockbridge 
Rockingham 
Russell 
Scott 
Shenandoah 
Smyth 
Southampton 
Spotsylvania 
Stafford 
Surry 
Sussex 
Tazewell 
Warren 
Washington 
Westmoreland 
Wise 
Wythe 
York 

 

Getting care when you need it

If the Governor of your state, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in your geographic area, you are still entitled to care from your plan.
For more information about the getting care during a disaster, refer to Chapter 3, Section 3 of Evidence of Coverage.

If you choose to go to a provider outside of our network without a referral from your PCP or prior authorization from the plan, you must pay for these services yourself except in limited situations (for example, emergency care or for urgently needed services or dialysis services when traveling outside of the plan service area ). Neither the plan nor Original Medicare will pay for these services.

If you need medical care that Medicare or Medicaid requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You must obtain prior authorization before seeing an out-of-network provider. In this situation, we will cover these services as if you got the care from a network provider. For information about getting approval to see an out-of-network provider, please contact Member Services at 1-800-624-3879 (TTY 711). Calls to this number are free. You can call 8 a.m. - 8 p.m., seven days a week.

For more information on getting care from out-of-network providers, refer to Chapter 3, Section 2.4 of the Evidence of Coverage.

If you need help with a grievance, coverage decision or appeal, you can ask someone to act on your behalf by naming another person to act for you as your “representative.” 
To give a friend, relative, your doctor or other provider, or other person the right to be your representative, call Member Services at 1-855-463-0933, TTY 711, and ask for the Appointment of Representative form. You also can download and print a copy of the Appointment of Representative form
The form must be signed by you and by the person whom you would like to act on your behalf. The completed and signed form is valid for one (1) year.
If your representative holds durable power of attorney or guardianship papers, an Appointment of Representative form is not required.

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 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.