Member materials and benefits

Coverage from head to toe

Looking to live a healthier life? Our benefits and programs are designed to help you do just that.

This coverage includes preventive services like doctor’s visits, lab testing, X-rays and more. Plus, we can help with serious health concerns. These may be chronic diseases or mental health issues. We also can connect you with resources in your community for other services.

Look at this section closely so that you can better understand your benefits. You’ll know what’s covered, what is not, and how you can find the right care when you need it.

Want to understand the details of your health plan? Review the Medicare-Medicaid Member Handbook and other documents below. These documents go over your benefits and shows what is covered and what is not. Plus, the documents also explain:

  • What a care management team
  • Our Pharmacy benefits
  • How to file grievances and appeals
  • How to find a doctor

Stay in-network and save
You must receive services covered by the health plan, from facilities and/or providers in the Aetna Better Health of Ohio network. The only time you can use providers that are not in the Aetna Better Health of Ohio provider network is for:

  • Emergency services
  • Federally qualified health centers/rural health clinics
  • An out-of-panel provider that Aetna Better Health of Ohio has approved you to see during or after your transition of care time period
  • Members that choose both their Medicare and Medicaid benefits through Aetna Better Health of Ohio can also receive urgently needed care and hospice services from non-contracting providers.

We provide services in only certain counties in Ohio. When you are out of our service area, you are only covered for emergency services. If you are out of the service area and need non-emergency services, call your PCP or Member Services.

Out-of-network and emergency care
Except in certain cases, like emergencies, you cannot visit a care provider outside of our network. “In network” providers are listed in our directory. These care providers have agreed to charge less for many services. If you do not use in-network providers, you may be responsible for these charges.

If you have questions about this, call Member Services at 1-855-364-0974 (toll-free), 24 hours a day, 7 days a week. TTY 711. You also can use the Find a Provider tool. 

How do I know if it’s an emergency?
For more information about emergency care, please review your Member Handbook. You can also call your PCP or our 24/7 Nurse Advice Line at 1-855-364-0974.

Behavioral health 
Your mental health is important
Behavioral health benefits cover services to help you improve your mental health. For example, if you suffer from mental illness, alcohol or drug addiction, you may need therapy or medicine. Your Aetna Better Health of Ohio covers many kinds of services for mental health. For more information, view your Summary of Benefits.

Care management
As a member of Aetna Better Health of Ohio, you will have your own care manager as part of our care management program. Your care manager can help you find the right care and services. Your care manager will contact you soon after you are enrolled with Aetna Better Health of Ohio.

A care manager will work with you, your doctors and other providers to make sure you receive the right care and services, with your needs in mind. The goal is to build a treatment plan just for you to help you live a healthier life. Your care manager will meet with you by phone or where you live as often as needed.

A care manager can help guide you if you have had any of these or other issues:

  • You are having to go to the ER a lot
  • You are having trouble getting things your doctor has ordered
  • Your doctor just told you that you have a disease like CHF (congestive heart failure) or diabetes but you would like to get more information about a disease or treatment
  • You need services to help you at home and need help getting long term services and support
  • Your doctor wants you to see a specialist, but you don't know what to do

If you want to discuss your health care needs and questions with your case manager, call Member Services to ask to speak to your care manager. Your care manager is there for you!

Disease management
Extra support to care for you

Our disease management programs are designed just for members with chronic (ongoing) conditions. This may include things like asthma, diabetes, lung disease or a heart issue.

What is a disease management program?

These programs provide education and outreach to you based on your medical needs. The goal is to help you be healthier and get quality care. If you choose to be part of our program, we work with the doctor to create a plan for your care. This plan will include goals that will help you and your doctor track your results. We will also provide education to you about how to stay well.

We have disease management programs for:

  • Asthma
  • Diabetes
  • Depression
  • Chronic Obstructive Pulmonary Disorder (COPD)
  • Congestive Heart Failure (CHF)

When you sign up for one of our disease management programs, we give you all the help we can. We will also connect you with other resources to help you manage your condition.

If you want to know more about our disease management programs, talk to your care manager or call the 24-hour Care Management line at 1-855-364-0974, (TTY: 711), 24 hours a day, 7 days a week. The call is free.

SilverSneakers®

SilverSneakers® is a valuable program that allows Aetna Better Health of Ohio members no-cost access to exercise equipment, group fitness classes, social events and more at participating gyms and fitness centers. Visit SilverSneakers.com to learn more, or call Member Services at 1-855-364-0974 (TTY:711).

Federal Free Cell Phone Program

Need a smartphone? Our Medicare-Medicaid members can receive a no-cost Android smartphone through the government's  Lifeline Program. This includes a monthly plan with data, talk, and unlimited texts as well as health tips and reminders by text, one-on-one texting with your healthcare team, and all calls with our Member Services department do not count towards your minutes. You also have the option to keep your current phone and choose a service-only monthly plan at no cost to you.

Please visit the Lifeline website to see how you qualify.

Non-Emergency Transportation

If you need a ride to your next doctor’s appointment, or simply need a way to get to and from the grocery store, library, or other plan-approved location, call member services at 1-855-364-0974 (TTY: 711) 3 days or more before your appointment. Aetna Better Health of Ohio will arrange to have a driver take you where you need to go and return you to your residence at no cost to you. 

Benefit includes up to 30 round trips, or 60 one-way trips per year. Aetna Better Health of Ohio requires that you call at least 3 days before your appointment to schedule a trip.

Dental services  

An additional Oral Exam, Cleaning, Fluoride Treatment and X-Rays per year for members 21 and older. This lets you get these services every 6 months instead of once per year. To access these services go to a dentist in the Aetna Better Health of Ohio network and show your Aetna Better Health of Ohio ID card.  If you have questions or need help finding a dentist call Member Services at 1-855-364-0974 (TTY: 711). This benefit is available to both Duals (Medicare and Medicaid) and Medicaid-Only members.

Over-the-counter medications

Our Medicare-Medicaid members can receive an OTC Network Card, pre-loaded every month with $50, to buy over-the-counter medicines and health-related items at participating retailers. 

Visit the OTC Network website to check the balance on your card, find participating retailers, review elgible over-the-counter items and more, or you can download the OTC Network app (availble in the Apple App Store, and Google Play). The app allows you to do all of this along with the ability to scan barcodes at participating retail stores to see if you can purchase those items with your card.

Talk to your Care Manager or call Member Services at 1-855-364-0974 (TTY: 711) 24 hours a day, 7 days a week, to learn more.


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 21, 2020

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

  • CMS will cover acupuncture for chronic low back pain (cLBP) effective for claims with dates of service on and after January 21, 2020.

This NCD expands coverage for acupuncture services specifically targeted for chronic low back pain. Medicare determined it will cover acupuncture for cLBP up to 12 visits in 90 days. These services will only be covered by Medicare if cLBP:

  • lasts 12 weeks or longer
  • nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc.
  • disease);
  • not associated with surgery; and
  • not associated with pregnancy

If you think you qualify, speak with your physician.

 

This summarizes CMS transmittal R10128NCD 

This affects services given on or after March 16, 2018

The Centers for Medicare & Medicaid Services (CMS) reviewed the evidence for laboratory diagnostic tests using NGS in patients with cancer. They determined that some tests could improve health outcomes for Medicare beneficiaries with advanced cancer. Testing will be covered for beneficiaries with:

  • recurrent, relapsed, refractory or metastatic cancer
  • advanced stages III or IV cancer if the beneficiary either:
    • has not been previously tested using the same NGS test for the same primary diagnosis of cancer or
    • will get repeat testing using the same NGS test only when the treating physician gives a new primary cancer diagnosis and there will be further cancer treatment (e.g., therapeutic chemotherapy) 

The test must be ordered by the treating physician, performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, and have all of the following requirements met:

  • Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and,
  • an FDA-approved or -cleared indication for use in that patient’s cancer; and,
  • results provided to the treating physician for management of the patient using a report template to specify treatment options

This summarizes CMS transmittal R210NCD

This affects services given on or after April 10, 2018

Medicare will allow for coverage of MRI for beneficiaries under certain conditions with any of the following: implanted pacemaker, implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), or cardiac resynchronization therapy defibrillator (CRT-D).

If you think you qualify, speak with your physician.

This summarizes CMS transmittal R208NCD

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 April 3, 2017.

Local Medicare administrators will decide if they'll cover topical oxygen for the treatment of chronic non-healing wounds.

This summarizes CMS transmittal R203NCD.

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

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 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 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 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 is effective for services on or after May 25, 2017.

The Centers for Medicare and Medicaid Services (CMS) issued an NCD to cover SET for beneficiaries with intermittent claudication (IC) for the treatment of symptomatic PAD.

SET involves the use of intermittent walking exercise, which alternates periods of walking to moderate-to-maximum claudication, with rest. SET has been recommended as the initial treatment for patients suffering from IC, the most common symptom experienced by people with PAD.

The SET program must:

  • Consist of sessions lasting 30-60 minutes, comprising a therapeutic exercise-training program for PAD in patients with claudication
  • Be conducted in a hospital outpatient setting, or a physician’s office
  • Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD
  • Be under the direct supervision of a physician (as defined in Section 1861(r)(1)) of the Social Security Act (the Act), physician assistant, or nurse practitioner/clinical nurse specialist (as identified in Section 1861(aa)(5) of the Act)) who must be trained in both basic and advanced life support techniques.

This summarizes CMS transmittal R206NCD.