Understand your rights

It is very important to us that you know all of your rights and responsibilities

As a member of Aetna Better Health you have certain rights and responsibilities. Knowing your rights and responsibilities will help you, your family, your doctor, and Aetna Better Health make sure that you get the covered services and care that you need.

As a member of Aetna Better Health, you have rights around your health care. You have the right to:

  • Get information about Aetna Better Health, our services, our practitioners and providers, and your rights and responsibilities.
  • Be treated with respect and dignity and have your privacy protected.
  • Get interpretation services if you do not speak English or have a hearing impairment.
  • Have materials presented in a manner or language that you understand, at no cost to you.
  • Not be discriminated against by Aetna Better Health.
  • Access all services that Aetna Better Health must provide.
  • Choose a practitioner or provider in our network.
  • Take part in decisions about your health care.
  • Accept or refuse medical or surgical treatment and choose a different provider.
  • Learn about other treatment options and different courses of care no matter how much they cost and/or if Aetna Better Health will pay for it.
  • Have your doctor tell you how he or she plans to treat you.
  • Your medical records.
  • Change or correct your medical records if needed.
  • Be sure your medical records are kept private.
  • Tell us how we can improve our policies and procedures, including the member rights and responsibilities policy.
  • Be free from any form of restraint or seclusion used as a means of force, discipline, convenience, or retaliation.
  • Get covered services, no matter what your cultural or ethnic background is or how well you understand English.
  • Get covered services regardless of any physical or mental disability, or if you are homeless.
  • Refer yourself to in-network and out-of-network family planning providers.
  • Access certified nurse midwife services and certified pediatric or family nurse practitioner services.
  • Get emergency post-stabilization services.
  • Get emergency health care services at any hospital or other setting.
  • Receive information about advance directives, which tell how to have medical decisions made for you if you are not able to make them for yourself.
  • Receive information about practitioner incentive plans upon request.
  • Have your parent or a representative make treatment decisions when you can’t.
  • Submit a complaint or appeal about Aetna Better Health or the services it provides.
  • A quick response to problems raised around complaints, grievances, appeals, authorization, coverage, and payment of services.
  • A state fair hearing after a decision has been made about your appeal.
  • A copy of this member handbook.
  • Disenroll from your health plan.
  • Get accessible services.

As a member of Aetna Better Health, you have the responsibility to:

  • Read your Member Handbook. It tells you about our services and how to file a grievance or appeal.
  • Work with your PCP to manage and improve your health.
  • Ask your PCP any questions you may have and call your PCP any time you need health care.
  • Give all information about your health to Aetna Better Health and your doctor. Tell your doctor if you do not understand your health problems. You and your doctor should make plans together about your care.
  • Show your ID card to each doctor before getting health services.
  • Protect your member ID card. Do not lose or share it with others.
  • Use the emergency room (ER) for true emergencies only.
  • Make and keep appointments with doctors. If you need to cancel and appointment, it must be done at least twenty-four (24) hours before your scheduled visit.
  • Follow what you and your practitioner agree to do.
  • Follow your practitioner’s recommendations about appointments and medications.
  • Go back to your PCP or ask for a second opinion if you do not get better.
  • Call Member Services at 1-888-348-2922 whenever anything is unclear to you or you have questions.
  • Contact DHHR Change Report Center at 1-877-716-1212 to report family size, employment, and/or address changes.
  • Treat doctors, staff, and people providing services to you with respect.
  • Tell Aetna Better Health if you have other health insurance, including Medicare.
  • Give your doctor a copy of your living will and/or advance directive.

As required by the West Virginia Department of Insurance, Aetna Better Health of West Virginia, Inc. is providing the following annual notice to HMO enrollees. You have the right to:

  • A description of your rights and responsibilities, plan benefits, benefit limitations, premiums and individual cost-sharing requirements.
  • A description of the health plan’s grievance procedures and the right to pursue grievance and hearing procedures without reprisal from the managed care plan.
  • A description of the method in which you can obtain a list of the plan’s provider network, including the names and credentials of all participating providers, and the method by which you may choose providers within the plan.
  • Choose an available participating primary care physician (PCP), and with proper referrals, the right to a participating specialist.
  • Privacy and confidentiality with regard to your personal information.
  • Full disclosure from your health care provider of any information relating to your medical condition or treatment plan and the ability to examine and offer corrections to your own medical records.
  • Be informed of plan policies and any charges for which you will be responsible.
  • Ask for the procedures Aetna Better Health uses to control the use of services and costs.
  • A description of the procedures for obtaining out-of-area services.
  • A description of the method by which you can obtain access to a summary of the plan’s accreditation report.
  • Have medical advice or options communicated to you without any limitations or restrictions being placed upon the provider or PCP by the health plan.
  • Have all coverage denials reviewed by appropriate medical professionals consistent with the health plan’s review procedure.
  • Have coverage denials involving medical necessity or experimental treatment reviewed by appropriate medical professionals who are knowledgeable about the recommended or requested health care service, as part of an external review as described in the Evidence of Coverage.
  • Emergency services without prior authorization if prudent layperson acting reasonably would have believed that an emergency medical condition existed, and the right to a description of procedures to obtain emergency services.
  • Direct access, annually, to your OB/GYN for the purpose of a well woman examination without a referral from your PCP, and no woman shall be required to obtain a referral from her PCP as a condition to coverage of prenatal or obstetrical care.
  • Reconstruction of the breast following mastectomy and reconstructive or cosmetic surgery required as a result of an injury caused by the act of a person convicted of a crime involving family violence. This applies a woman whose plan provides coverage for surgical services in an inpatient or outpatient setting.
  • Following when performed for cancer screening or diagnostic purposes: (1) a baseline mammogram for women age thirty-five to thirty-nine, inclusive; (2) a mammogram for women age 40 to 49, inclusive, at least every two years; (3) a mammogram every year for women age 50 and over; (4) a pap smear at least annually for women age 18 and over. This applies to a woman whose plan provides coverage for laboratory or X-ray services.
  • Colorectal cancer examinations and laboratory tests for colorectal cancer for a non-symptomatic person over 50 years of age and symptomatic person under 50 years of age.
  • Rehabilitation services.
  • Child immunization (shots) services, which shall not be subject to payment of any deductible, per-visit charge and/or copayment.
  • Direct access to an optometrist or ophthalmologist of your choice from the panel without referral from your PCP for an annual diabetic retinal examination for diabetics whose health benefits policy includes eye care benefits. When the diabetic retinal examination reveals the beginning stages of an abnormal condition, access to future examinations shall be subject to prior authorization from a PCP.
  • Obtain your prescription drugs from a retail pharmacy.
  • Any combination of blood pressure testing, urine albumin or urine protein testing and serum creatinine testing as recommended by the national Kidney Foundation when performed for kidney disease screening or diagnostic purposes at the direction of a person licensed to practice medicine and surgery by the board of medicine.
  • Aetna Better Health of West Virginia encourages our members to exercise their rights and by exercising the rights the members will not be treated poorly.
  • General anesthesia for dental procedures and associated outpatient hospital or ambulatory facility charges provided by appropriately licensed health care individuals in conjunction with dental care if you are: • Seven years of age or younger or are developmentally disabled and are an individual for whom a successful result cannot be expected from dental care provided under local anesthesia because of a physical, intellectual or other medically compromising condition and for whom a superior result can be expected from dental care provided under general anesthesia; or
  • A child who is twelve years of age or younger with documented phobias, or with documented mental illness, and with dental needs of such magnitude that treatment should not be delayed or deferred and for whom lack of treatment can be expected to result in infection, loss of teeth, or other increased oral or dental morbidity and for whom a successful result cannot be expected from dental care provided under local anesthesia because of such condition and for whom a superior result can be expected from dental care provided under general anesthesia.

You have the right to make decisions about your medical care. An advance directive documents your health care decisions when you cannot speak for yourself. It tells your provider what future health care wishes you have if you are too sick to tell them yourself. This is the only time the advance directive is used.

Advance directives can include a living will or durable power of attorney for health care. Your advance directive is included in your medical records. You should tell your provider if you have certain moral and/or religious beliefs that would stop you from making advance directives. Your doctor or other health care provider should write down your objections to making advance directives and will make this a part of your medical records.

Aetna Better Health of West Virginia Community Report

A copy of the Aetna Better Health of West Virginia Annual Report is available to you. If you would like to receive a copy, call Member Services at 1-888-348-2922.