How to use your benefits

Member ID cards – You should carry your Aetna Better Health ID card and your West Virginia Medicaid card with you at all times. Your ID card is the key to getting all of the health care services to which you are entitled.

The back of your card provides you with the Aetna Better Health Member Services Department and 24 hour Nurse Line phone numbers.  You will receive a member ID card for each covered member of your family. If you did not receive a member ID card for each covered family member or need to add a new family member call us at 1-888-348-2922. If you need to replace a lost or stolen member ID card, tell us.

If you need help finding a provider, call Member Services at 1-888-348-2922. Our staff can help you find a provider or mail you a provider directory. You can always search for a provider.

 

When you enroll with Aetna Better Health, you are required to select a personal doctor. This doctor is known as your PCP. Your PCP is the doctor who directs all of your health care services. As soon as you get your ID card, set up time to see your PCP for a checkup. Do this even if you are not sick. This way, your PCP can get to know you better and help stop future health problems before they happen, or at least find them sooner. 

Your PCP knows your health care history. He or she is best prepared to direct treatment when, and if, it is needed. 

Children and teenagers should also see their PCP for checkups, shots and screenings as soon as possible. For checkups, shots and screening, call your PCP two to three weeks ahead to ask for an appointment.

We cover care given by a licensed Aetna Better Health of West Virginia practitioner. You may receive care in the practitioner’s office, a clinic, or other places needed to treat an illness, injury or disease. You may also receive care at these places for family planning, maternity care, and well-child screenings under the EPSDT program or other preventive care. 

 

 

Specialty care Sometimes you or your child may need care from a specialist. Specialists treat special types of conditions. These conditions include behavioral health or substance use problems. Your PCP can give you the name of a specialist or behavioral health care provider. You don’t need a referral as long as the specialist is in our provider network. Women’s health specialists Female members age 13 or older may get female-related services. These include routine and preventive care directly from an obstetrical/gynecological physician (also called an OB/GYN) in our network. You do not have to ask your PCP before getting these services. You can pick the PCP from our provider directory.

Family Planning Services

Family planning helps you plan your family size. It gives you information on birth control methods. Family planning is covered for Aetna Better Health of West Virginia members of child‑bearing age. Any care given is kept private. You may pick a family planning practitioner and get covered family planning services from one of our network providers. Family Planning services do not require prior authorization.

Referrals

You do not need to get a referral from your PCP before you see another Aetna Better Health provider. Call your PCP to let them know that you are going to the other provider. Your PCP should be coordinating your care.

How to get a second medical opinion

You may need a second opinion for an illness or surgery. You may also need one for a treatment your doctor said you need. Call your doctor or Member Services for help to get a second opinion. If you can’t find a provider for the second opinion in our network, we will help you find one outside our network. There is no cost to you for the second opinion.

Continuing services from providers

You may be able to continue services if your PCP leaves our network. If your provider leaves our network, call Member Services for help.

Behavioral Health – Mental health services and drug and alcohol treatment

What are behavioral health services?

  • Outpatient behavioral health services, such as counseling for depression or substance abuse treatment
  • Inpatient psychiatric services for members under 21 years of age

Your behavioral health benefits are covered by Aetna Better Health. You will need to show your Aetna Better Health ID card when you have behavioral health visits. If you have any questions about coverage for behavioral health services, just call Member Services.

Hospital care

Aetna Better Health must approve (preauthorize) your stay before you go to the hospital. You must go to a hospital that is in our network. We’ll help manage all hospital stays. The care is covered as long as there is a medical need. Aetna Better Health will follow you during your stay and help with any discharge needs you may have.

 

24-Hour care – Your PCP
You will choose a PCP (primary care physician) who can take care of all of your health needs. Call your PCP for care anytime, day or night, weekends and holidays. When your PCP is out, they have someone to take their place. Your PCP, or the on-call doctor for your PCP, will help you any time, 24 hours a day. For routine and urgent care, call your PCP. To see your PCP, just call the doctor's office and make plans for a visit. If you need health care and your PCP's office is closed, you should still call his or her office and tell them you are an Aetna Better Health member. Your PCP or someone from his or her office will call you back.

24-Hour Nurse Helpline – 1-855-200-5975
It’s best to work with your PCP for your health care needs. But if you have a medical question and don’t know what to do, call our 24-hour Nurse Helpline. The Nurse Helpline can answer your health questions. They can help you decide what to do when you need health care. They can tell you if you should call your PCP, make an appointment or go immediately to the emergency room. The toll-free number for the Nurse Helpline is 1-855-200-5975. This number is also on your ID card.

If you get sick while you are away from home, call your PCP or the 24-Hour Nurse Helpline. Your PCP or a nurse can tell you what type of treatment you need and if you should see a doctor. If you need treatment and are too far away to see your PCP within 24 hours, Aetna Better Health will help you find a provider or urgent care center nearby.

If you need emergency treatment and you are outside of the Aetna Better Health service area, you should go to the nearest urgent care center or hospital. Please let the hospital know that you are an Aetna Better Health member and have the hospital call Member Services Department. If you are at a hospital that is not in the Aetna Better Health network, we may ask you to move to another hospital in our network when you are well enough to do so.

If you need emergency care, and do not have immediate access to a hospital or doctor, you should call 911.

If you have an emergency, you may not have time to call your PCP. If you do have time to call, he or she will help you decide what to do. If it is after your doctor’s regular office hours, you should call the after-hours number for your doctor. Keep this number in a place you can get to quickly when you need it. Your PCP or a doctor on call for your PCP can be reached 24 hours a day.

If you need an ambulance for an emergency, call 911. Ambulance service is only covered when there is an emergency or when Aetna Better Health has (approved) preauthorized it.

Hospital emergency rooms that are not in the Aetna Better Health network should be used only when the delay of a longer travel time to a hospital within the network could cause the member’s condition to worsen if left unattended.

For more information on seeking care outside the network or during an emergency, please see your member handbook.

You can go to any in-network practitioner without a referral. Some services may require prior authorization. If you prefer, you can choose a women's health specialist to be your PCP.

You can get the following services from out-of-network providers without referral or approval from Aetna Better Health:

  • ›Emergency services
  • ›Family planning
  • ›Treatment for sexually transmitted diseases (STDs)

If you have a chronic or severe illness like HIV or AIDS, we encourage you to talk with your primary care provider (PCP) about your care.

We will help direct the care of members with health problems. Aetna Better Health has nurses to assist members, doctors and hospitals with making sure needed health care is performed when needed. Aetna Better Health will direct your care between the PCP, the specialist and the hospital. We follow standard health care rules for routine screening, case management, and hospital stays. These rules are used by our health care staff to decide what treatment you should receive. 

Aetna Better Health must approve (preauthorize) some health care and supplies you get. We will give preauthorization to Aetna Better Health providers when you need health care or supplies that are medically needed and listed below. Your doctor needs to call Aetna Better Health for approval at least three working days before the scheduled care. Aetna Better Health may ask to see written notes showing that the care was medically needed before it is preauthorized.     

Your preauthorization for care is for a specific problem or sometimes for a set number of visits. If you run out of visits and still need more, call your doctor. Your doctor must call us to add more visits.   

Aetna Better Health updates the Preauthorization list from time to time. Call Member Services Department for a copy of the most current preauthorization list or if you are not sure about a certain service or injectable. You can speak to a person to ask questions about the pre-approval/prior authorization process by calling Member Services Department 24 hours a day, 7 days a week. After normal business hours, you may need to leave a message for someone to return your call the next business day. If a UM employee calls you, they will give you their name and title and say they are calling from Aetna Better Health. You can also access TTY services or language assistance to talk about UM issues by dialing 711.

Preauthorization List

 

Our Utilization Management Policy
Our UM program helps make sure you get the right services at the right place. When we make decisions, it's important for you to remember the following:

  • We make decisions by looking at your benefits and choosing the most appropriate care and service.
  • We don't reward doctors or other people for denying coverage or care.
  • Our employees do not get any incentives to reduce the services you get.

If you would like a copy of our complete Utilization Management Policy, please contact Member Services Department at 1-888-348-2922.

Aetna Better Health will remain current with reviewing new technology to be included as a covered benefit. Aetna Better Health will review medical literature to help pick the technologies that will provide medically needed care and is approved by any regulating body required by law to do so. The new technologies must show improvement in the health risk of a member over current products or procedures. Care or supplies must be medically needed to be covered. Medical need is decided by looking at the generally accepted standards of care. Aetna Better Health decides whether the care meets these standards.