AETNA BETTER HEALTH OF NEBRASKA

Transcription

1 AETNA BETTER HEALTH OF NEBRASKA Member Handbook Nebraska Medicaid Managed Care Program

2 As an Aetna Better Health of Nebraska member, you get: Regular wellness checkups to keep adults and children healthy New moms program and gift card Portable crib program Hearing and vision services Ted E. Bear, M.D. SM Kids Club Helpful website with provider look-up Paid Boy and Girl Scouts Memberships Informed Health Line Adult immunizations Important phone numbers Member Services (TTY 711) TDD Informed Health Line (24-hour nurse line) (TTY 711) Emergency: 911 Transportation (TTY ) (Omaha area ) Dental Block Vision (TTY ) Magellan (Behavioral health/substance use disorder services) (TTY 711) Pharmacy Mailing address West Dodge Road Omaha, NE Personal information and contact list My member ID number My primary care provider (PCP) My PCP s phone number

3 AETNA BETTER HEALTH OF NEBRASKA Welcome to Aetna Better Health of Nebraska. Your decision to join Aetna Better Health of Nebraska (Aetna Better Health) is an important one for you and your family. We welcome you. We have a strong network of providers, hospitals and other health care providers. They offer a broad range of services for your medical needs. It is important that you understand how your plan works. This Member Handbook has the information you need to know about your Aetna Better Health benefits. Please take some time to read this Handbook. Our Member Services department is ready to answer any questions. Call (TTY: 711 or TDD: ), Monday through Friday, 8 a.m. to 6 p.m. Central Time and 7 a.m. to 5 p.m. Mountain Time. Call 711 if you have a speech or hearing problem and use a TTY. Or find us on the web at. We look forward to serving you and your family. Sincerely, Shelley Wedergren Chief Executive Officer This Handbook is available in audio version. Please call (TTY: 711 or TDD: ) for a copy. Este manual es disponible en español. Llame (TTY: 711 o TDD: ) para una copia. 1

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5 Table of Contents Definitions... 5 Section 1: Important information about your Aetna Better Health of Nebraska coverage...10 About your coverage...10 Extra Aetna Better Health benefits...10 Benefits available from the state...11 Communication/translation services...12 Foreign languages spoken at provider offices...13 Transportation...19 Section 2: Rights and responsibilities...36 Your rights and responsibilities...36 Availability of care...39 Advance directives...40 Section 3: Enrollment and eligibility...41 Enrollment...41 Causes for disenrollment...41 Changes you need to report...42 ID cards...42 Section 4: Getting help...44 Member Services...44 Communication/translation services...44 Foreign languages spoken at provider offices...46 Aetna Better Health online...46 Case management program/disease management program...47 Social worker services...47 Satisfaction survey...48 Section 5: Using your benefits...49 Primary care provider (PCP)...49 Choosing and changing your primary care provider (PCP)...49 Specialists...50 Getting care...51 Second opinion...52 Direct access to care...52 Family planning and treatment for STDs...52 Out of network providers...53 Medical help away from home...53 Notice of changes...54 Reporting fraud and abuse

6 Section 6: Covered services and limits...55 Copayments...55 Pre authorization...56 Pre authorization...65 What if I get a bill?...66 Other insurance...66 Telehealth services...67 New technologies...67 Health survey...67 Section 7: General services not covered...68 Services not covered...68 Section 8: Emergency services and urgent care Emergency and urgent care...69 Section 9: Routine screening, testing and cancer related checkups...71 Wellness care for adults...71 Wellness care for children...71 Section 10: Special programs...73 Ted E. Bear, M.D. SM Kids Club...73 Boy and Girl Scouts...73 Pregnancy programs...73 Informed Health Line...75 Section 11: Grievances and appeals...77 Complaint, grievance and appeal procedures...77 Complaint/grievance...77 Appeal...78 Expedited (fast) appeals...80 State Fair Hearing process...80 Your benefits during the appeal or State Fair Hearing process...81 Inquiries...81 Section 12: Confidentiality and privacy...83 Confidentiality and request for your medical records...83 Your privacy matters

7 Definitions Action: Something you may appeal such as: Denial or limited authorization of a requested service, including the type or level of service Reduction, suspension or termination of a previously authorized service Denial, in whole or in part, of payment for a service Failure to provide services in a timely manner, as defined by the state Failure of a managed care organization (MCO) to act within specified timeframes Adult: A member who is age 21 or older. Appeal: A request for review of an action. Authorization/pre authorization: Also called pre certify. Approval by the plan that is needed before certain services are provided so that the plan will pay for the services. Benefit year (state): July 1 through June 30. Child/children: A member(s) who is under age 21. Complaint: A way for you to let us know you are unhappy about any matter other than an action. Cosmetic services and surgery: Services and surgery that are mainly to improve your looks. Cosmetic services and surgery do not help your body work better or keep you from getting sick. Copayment: An amount you pay when you have certain medical services Covered services (covered care): The medical care, services or supplies, which Aetna Better Health will pay. This care is described in this Handbook. Member Services department: The Aetna Better Health staff who answer questions about your Aetna Better Health benefits. The toll free numbers are (TTY: 711 or TDD: ). Staff members are available Monday through Friday from 8 a.m. to 6 p.m. Central Time and 7 a.m. to 5 p.m. Mountain Time, except holidays. Dependent: Any person in a member s family: Who is eligible to be covered under this Handbook; and Who is enrolled in the Aetna Better Health program DHHS: Nebraska Department of Health and Human Services. 5

8 Disenrollment: (1) A change in the status of a client from being enrolled with a specific health plan or primary care provider (PCP) to being enrolled with a different health plan or PCP; OR (2) A change from being allowed to participate in managed care to not being allowed. Early and Periodic Screening, Diagnosis and Treatment (EPSDT): A program of preventive health care and well child checkups with age appropriate tests and shots. Emergency medical condition: A medical condition (including emergency labor and delivery) showing acute symptoms of sufficient severity (including severe pain) where the absence of immediate medical attention could reasonably be expected to result in: Serious jeopardy to the patient s health or the health of a woman and her unborn child Serious impairment to bodily functions Serious dysfunction of any bodily organ or part Emergency services: Covered inpatient or outpatient services that are provided by a qualified Medicaid provider and are needed to evaluate and stabilize an emergency medical condition. Enrollment broker (EB): A company the state contracts with to assist members with choosing a health plan and primary care provider (PCP), and who does other enrollment activities. Experimental or investigational: A service, supply, equipment, drug or procedure is experimental or investigational if one or more of the following are met: Any drug not approved for use by the Food and Drug Administration (FDA); any drug that is classified as an investigational new drug (IND) by the FDA; any drug where pre authorization is requested that is proposed for off label use, except as otherwise required by state law Any service, supply, equipment, drug or procedure that is subject to the review and/or approval of our corporate medical management team Any service, supply, equipment, drug or procedure that is the subject of a clinical trial that meets criteria for Phase I or II, as set forth by FDA regulations, or Phase III approved for the treatment of cancer by the National Institute of Health Any service, supply, equipment, drug or procedure that is considered not to have demonstrated value based on clinical evidence reported by peer reviewed medical literature and by generally recognized academic experts Family planning services: Family planning services help you plan your family size. Services include information on birth control methods. 6

9 Grievance: A way for you to let us know you are unhappy about any matter other than an action. Immunization: A medicine that helps the body fight disease. Inquiry: An oral or written communication that Aetna Better Health Member Services receives from members or member representatives. Managed care organization (MCO): The health plan providing your Medicaid benefits. Medical home: Your primary care provider (PCP) is your medical home. A medical home helps make sure you get the right medical care when you need it. Care is given by a provider who knows you and your health needs. Medically needed/medical necessity: Health care services and supplies that are medically appropriate and: Necessary to meet the basic health needs of the member Delivered in the most cost efficient manner and type of setting appropriate for the delivery of the covered service Consistent in type, frequency, and duration of treatment with scientifically based guidelines of national medical research, or health care coverage organization or governmental agencies Consistent with the diagnosis of the condition Required for means other than convenience of the client or his or her provider No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency Of demonstrated value At a level that is no more intense than can be safely provided The fact that the provider has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular injury, sickness, or mental illness does not mean it is covered. Services and supplies which do not meet the definition of medical necessity are not covered. Member: Any person who gets services from the Department of Health and Human Services (DHHS) and who has Aetna Better Health coverage. Member Handbook (Handbook): This book as well as any amendment, or related document sent together with this book, that tells you about your coverage and your rights. Post stabilization care: Medically needed care a member gets after an emergency condition has been controlled. 7

10 Primary care provider (PCP): A health care provider you choose or assigned by Aetna Better Health to give your main health care (i.e. General Practice, Family Practice, Pediatrician, Internal, OB/GYN, Physician Assistant and Nurse Practitioner). Provider/participating provider: A provider, hospital, or other licensed institution or health professional, such as a nurse midwife who has directly or indirectly signed a contract with Aetna Better Health to be part of its Aetna Better Health network. These providers are also called participating providers. The provider directory will list these Aetna Better Health providers. This is also known as an in network provider. In network provider: A health care provider who is in Aetna Better Health s provider network. Out of network provider: A health care provider who is not in Aetna Better Health s provider network. The list can change and is available by calling Member Services or visiting our website at. Prudent layperson: A person who does not have medical training, but who uses his or her practical experience to make a decision regarding whether or not emergency medical treatment is needed. A prudent layperson will be considered to have acted reasonably if another layperson would have made the same decision in the same situation. Restricted services: The Restricted Services Program provides guidance to members who need assistance in managing health care. Support is provided through structured access to a primary care provider (PCP), and/or a pharmacy, and/or a hospital. Service area: The geographic area where you can get care under the Aetna Better Health program. Specialty care provider/specialist: A provider who gives health care to members within his or her range of specialty. For the purposes of this Handbook, a specialty care provider does not mean an OB/GYN since an OB/ GYN is a PCP. Examples of specialists include: Foot providers Eye providers Cancer providers Surgeons Heart providers Skin providers Providers for women s issues Providers for blood problems Ear, nose and throat providers 8

11 Urgent care: Medically needed care for an unexpected illness or injury for which you need services sooner than you could get in to see your provider, but the situation is not serious enough for you to go to an emergency room. You/your: Refers to a member. Working day: Any day between Monday and Friday, and does not include public holidays or weekends. 9

12 Section 1: Important information about your Aetna Better Health of Nebraska coverage About your coverage If you need to contact someone about your Aetna Better Health coverage, please contact: Aetna Better Health Member Services department W. Dodge Rd. Omaha, NE (TTY: 711 or TDD: ) If you have a medical question, the Informed Health Line (TTY: 711) can answer your medical questions 24 hours a day, seven days a week. They can answer questions about your symptoms and what you should do. Please make sure you read and understand the grievance procedure in this Handbook. Please read it before taking any other action. Below are the addresses and telephone numbers for Complaints/Grievances and Appeals: Complaints/Grievances Aetna Better Health of Nebraska Member Services department W. Dodge Rd. Omaha, NE (TTY: 711 or TDD: ) Appeals Aetna Better Health of Nebraska Appeals Coordinator W. Dodge Rd. Omaha, Nebraska (TTY: 711 or TDD: ) Extra Aetna Better Health benefits Adult flu shots Routine adult Immunizations Routine adult checkups Referrals not needed to see an in network specialty care provider/specialist 10

13 Disease management programs Asthma Chronic renal failure Congestive heart failure Coronary artery disease COPD Diabetes HIV/AIDS High risk pregnancy Hypertension Low back pain Multiple sclerosis Obesity Sickle cell Informed Health Line (TTY: 711) Pregnancy programs: Healthy Mom, Happy Baby Portable Crib program Postpartum reward program Childbirth education classes High risk pregnancy program Text4baby text messaging program Breast pump coverage Member Advisory Board: This committee allows Aetna Better Health to hear from members about how we can better serve you. For more information, call Member Services at (TTY: 711 or TDD: ) Member ID card Member newsletter Preventive health education mailings Benefits available from the state Some services are covered by the State of Nebraska. Please call the numbers below to learn how to receive these benefits: Dental: You may need to pay up to $3 copayment for services. Behavioral health and substance use disorders: Magellan Health Services at You may have a $2 copayment for these services. Pharmacy (except birth control) You may have a $2 copayment for generic drugs or $3 copayment for brand name drugs. Transportation IntelliRide at Local Omaha are call TTY: Additional information on page

14 Nursing facility long term care ACCESSNebraska at (if in the Lincoln area, call ; if in the Omaha area, call ) or HCBS waiver services ACCESSNebraska at Local Lincoln area call Local Omaha area call or visit Hospice ACCESSNebraska at Local Lincoln area call Local Omaha area call or visit Communication/translation services We want to make sure you understand your benefits. Member Services can help if you: Have problems hearing (TTY: 711 or TDD: ) Have problems seeing other format available Have problems reading other format or interpreters available Do not speak English translated materials in Spanish are available Interpreter services: If you do not speak or understand English call (TTY: 711 or TDD: ) to ask for help. We will get you an interpreter when needed. We have this book in Spanish. All Interpreter services are free. Si usted no entiende Inglés, por favor llame al: (TTY: 711 o TDD: ) y nosotros le proveeremos la información acerca de sus beneficios en español. También podemos ayudarle a comunicarse con su médico. Este servicio es gratuito. 12

15 Foreign languages spoken at provider offices If you speak a language other than English, please check our provider directory for a provider who speaks your language. If you need a free provider directory, call Member Services at (TTY: 711 or TDD: ) and we will mail one to you. Or, go to for a provider list. You can also use the Provider Search on our Website for the most up to date provider information. Interpretation services are free. 13

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21 Transportation Do you need a ride to your appointment? You may have transportation benefits offered through Medicaid. Aetna Better Health does not provide non emergency medical transportation. To see if you are eligible for transportation, call IntelliRide at , local Omaha call (TTY: ) or visit What information do I need to know when I call? The street address including city and zip code of your pick up and drop off locations and telephone number If you have a Nebraska Medicaid ID number, please have it ready for the IntelliRide reservation specialist For minors age12 and under, you need the name of the adult traveling with the child Transportation is available to the provider of choice within 20 miles radius of your home or the closest available provider Am I eligible to receive transportation? Call (TTY: ) to see if you qualify (local Omaha call ). IntelliRide can check to see if you qualify for transportation. How will I get to my appointment? Depending on your needs, IntelliRide can offer you: Mileage reimbursement for another person using their own vehicle to drive you to your appointment (examples: family member, friend or neighbor) Public transit Commercial vehicle Wheelchair lift equipped vehicle Escort Commercial air, bus and train Traveling with kids: For minors aged 12 years and under with an appointment, only one adult, at least 19 years of age, may ride. Children without an appointment may not ride along. You must provide a car seat or booster seat based on the child s age and weight. When do I have to call? You must call at least three working days before your appointment. You can schedule a ride up to 30 days before your appointment. IntelliRide may approve transportation that extends beyond the initial 30 days in some situations. 19

22 What if I can t give three working days notice? Urgent medical trips can be requested with less than 3 days notice. IntelliRide may check with your provider to make sure the appointment is urgent. Other information: If you have scheduled a return ride, your ride will arrive within 15 minutes after your appointment is over. If your wait is longer than 60 minutes, call select option 2 and a Member Services representative will help you. What if I have a complaint? You can file a complaint if you: Do not agree with a decision made by IntelliRide Are not happy with any services received Are not happy about any other part of IntelliRide You may do this by calling IntelliRide at , extension 1003 (TTY: ), or write it down and send it to: IntelliRide 2222 Cuming Street Omaha, NE For transportation services: , local Omaha call , (TTY: ) 20

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38 Section 2: Rights and responsibilities Your rights and responsibilities As a member of Aetna Better Health, you have the right to: Choose a primary care provider (PCP) as your medical home. Be treated with respect, dignity and privacy. Be free from any form of restraint and/or seclusion used as a means of coercion, discipline, convenience or retaliation. Get covered benefits or services regardless of gender, race, ethnicity, age, religion, national origin, sexual orientation, physical or mental disability, type of illness or condition, genetic information, ability to pay or ability to speak English. Not have your medical records shown to others without your approval, unless allowed by law. Privacy when you are at an office visit, getting treatment or talking to the health plan. Seek advice and help. Receive considerate, respectful, timely, and appropriate care, treatment and services for physical and emotional problems. Tell Aetna Better Health ways to improve its policies and procedures, including the Member Rights and Responsibilities. Request additional information about the structure and operation of Aetna Better Health. Receive information regarding physician incentive plans, if applicable. Be involved in deciding on the kind of care you want or do not want. Get information about Aetna Better Health, the services it covers, the providers who provide care, and the Member s Rights and Responsibilities, annually. Have your provider tell how he or she plans to treat you: The provider should tell you if other treatments can be used and the risks for each one no matter how much they cost or if Aetna Better Health will pay for it. This information should be easy to understand Receive and understand current information concerning your diagnosis, treatment and prognosis. Receive considerate, respectful, timely and appropriate care, treatment and services for physical and emotional problems. Get guidance for more medical care if your health care coverage ends. Find out what is in your medical records, as allowed by law, and request a copy of your records. You may be charged for this. Ask that changes be made to your medical records, if there are any errors on your records. Voice your complaints, grievances and appeals, and/or request a State Fair Hearing about Aetna Better Health and the care you get from your provider. 36

39 Know how Aetna Better Health pays providers, controls costs and uses services. Say no to treatment, services or PCPs, and be told what may happen if you do not have the treatment: You can continue to get Medicaid and medical care without any repercussions even if you say no to treatment. Get information about changes in benefits at least 30 days before the change. Ask for an emergency transfer from your PCP if your health or safety are in danger. Ask for materials to be presented in a manner or language that you understand at no cost to you, including enrollment notices, informational materials, instructional materials and treatment options. Have managed care and health plan materials explained if you do not understand. Get a full description of your disenrollment rights at least once a year. Get interpretation services if you do not speak English or have a hearing impairment to help you get the medical services you need at no cost. Get services that are correct. They should not be denied or reduced because of your diagnosis, type of illness or medical condition. Exercise your rights. It will not affect the way Aetna Better Health, our providers or the state agency treats you. Pick a provider who works with Aetna Better Health s provider network. Know the cost to you if you choose to get a service that Aetna Better Health does not cover. Get a second opinion from an appropriately qualified participating health care professional at no cost to you. If an Aetna Better Health provider is not available, Aetna Better Health will help you get a second opinion from a non participating provider at no cost to you. Use the methods listed in the Handbook to share questions and concerns about your health care or Aetna Better Health. Develop advance directives or a living will, which tell how to have medical decisions made for you if you are not able to make them for yourself. Get emergency health care services without the approval of your primary care physician (PCP) or Aetna Better Health when you have a true medical emergency. Be told in writing by Aetna Better Health when any of your health care services requested by your PCP are reduced, suspended, terminated or denied. You must follow the instructions in your notification letter. Receive reasonable continuity of care. Respect and privacy. Be free from restraints. Have privacy in your room. 37

40 Receive a timely, courteous and reasonable response from Aetna Better Health, health care providers and staff. Receive requests or grievances in writing, if requested. Manage your own financial affairs. Be fully informed of all rights and responsibilities. Receive a written itemized statement of charges and services. Inspect all records pertaining to you. Your responsibilities as an Aetna Better Health member are to: Tell Aetna Better Health and ACCESSNebraska about changes in your family that might affect eligibility or enrollment: Some examples are change in family size, employment and moving out of the state of Nebraska. Tell Aetna Better Health and the ACCESSNebraska when your name, telephone number or address changes. Treat Aetna Better Health staff and your health care providers with respect and dignity. Protect your member identification (ID) card: Do not lose or share it with others. Call Member Services if you lose your Aetna Better Health Member ID card or if it is stolen. Show your identification (ID) card to each provider before getting health services. Make and keep appointments with your providers: If you need to cancel an appointment, it must be done at least twenty four (24) hours before your scheduled visit. Get medical care from in network providers. This does not include care for family planning or for emergencies, which may be provided by out of network providers. Follow what you and your provider agree to do: Make follow up appointments. Take medicines and follow your provider s care instructions. Use the emergency room (ER) for true emergencies only. Give all information about your health to Aetna Better Health and your provider. Understand what medicine to take. Tell your provider if you do not understand what he or she tells you about your health so that you and your provider can make plans together about your care. Read the Member Handbook: It tells you about Aetna Better Health services and how to file a complaint or grievance. Follow Aetna Better Health rules. Know the name of your assigned PCP. 38

41 Schedule wellness checkups: Members under twenty one (21) years of age need to follow the Early Periodic Screening Diagnosis and Treatment (EPSDT) schedule. Get care as soon as you know you are pregnant: Keep all prenatal appointments. Tell Aetna Better Health if you have other health insurance, including Medicare. Give your provider a copy of your living will and/or advance directive. You have a responsibility to follow Aetna Better Health rules. We may ask you to be disenrolled if you do not follow the rules. Our member rights and responsibilities statement is updated each year. For more information on rights and responsibilities, call Member Services at (TTY: 711 or TDD: ). Aetna Better Health does not take action against members who exercise their rights. Availability of care You have a right to be seen by a provider within certain timeframes. The timeframes depend on the type of appointment you need. A typical working day is defined as any day between Monday and Friday, and does not include public holidays or weekends. You may ask for a specialist as your PCP if you have a chronic illness or special need. Please call Member Services if you have a problem scheduling any appointment, or cannot be seen within these timeframes: Primary care provider (PCP) Emergency Urgent care Routine Specialist Routine Pregnancy care First trimester Second trimester Third trimester (high risk) 24 hours per day, 7 days per week 2 calendar days 14 working days 30 working days 14 working days 7 working days 3 working days 39

42 Advance directives An advance directive is a statement you make about the medical care you would like before you need the care. There are different types of advance directives: Living wills a written statement describing the type of life support you want or do not want if you become very sick or are suffering from a terminal illness. Durable power of attorney for health care a document you sign in which you name another person to make your medical decisions for you if you are medically or mentally unable to do so. In order to sign a living will or a durable power of attorney for health care, you must be at least 19 years old and competent. If younger than 19 years old, you must be either married or divorced, and competent. Nebraska law recognizes both living wills and durable powers of attorney for health care. Aetna Better Health will tell you if the law changes within 90 days of the change. Your health care provider or Aetna Better Health case manager will help you write down your wishes or make a copy of your written wishes if you have already written them. These wishes or advance directives will be made a part of your medical records. You may change your mind at any time by putting your change in writing. To request information from an Aetna Better Health case manager, please call (TTY: 711 or TDD: ). You should tell your PCP or other health care provider if you have certain moral and/or religious beliefs that would stop you from making advance directives. Your PCP or other health care provider will write down your objections to making advance directives and will make this a part of your medical records. Aetna Better Health supports your right to have advance directives and to have your instructions followed by your health care providers. If you have concerns about a provider not following your wishes, you may file a complaint with the State Professions and Occupations Investigations Unit: Nebraska Department of Health and Human Services Division of Public Health Investigations 1033 O Street, Suite 500 Lincoln, NE

43 Enrollment Section 3: Enrollment and eligibility Nebraska s Medicaid Enrollment Center and Aetna Better Health help you sign up with an in network provider. This is so that you have a medical home for all your health care needs. We also work with Nebraska Medicaid if there are any problems with enrollment. Aetna Better Health accepts all eligible members. We do not treat you differently because of your: Health or need for health care Race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information or source of payment Medicaid Enrollment Center: In Lincoln area, call: Causes for disenrollment You may ask to leave a health plan: For cause, at any time, for things like: Poor medical quality of care Lack of access to covered medical services Lack of access to medical providers To request to be disenrolled with cause, call the Medicaid Enrollment Center at Local Lincoln call You may also write to them at: The Medicaid Enrollment Center 4600 Valley Road, Suite 300 Lincoln, NE You may disenroll, without cause, for the following reasons: For any reason in the first 90 days of being a health plan member or after the state sends you a Notice of Enrollment, whichever is later After your first 90 days of enrollment, once every 12 months for any reason Upon automatic re enrollment if the temporary loss of Medicaid eligibility has caused the member to miss the annual disenrollment opportunity When the state imposes intermediate sanctions on your health plan 41

44 Changes you need to report You could lose your insurance if the state cannot contact you. If we do not know where you live, you will miss important information about your coverage. Your baby will not have insurance until you call to enroll the baby. If you have a baby, move or change your phone number: Report your new information to ACCESSNebraska If you live in the Lincoln area call If you live in the Omaha area call All other areas call Or go to Then call Aetna Better Health at (TTY: 711 or TDD: ). Be sure to read all mail and return any phone messages from the state and Aetna Better Health. ID cards Each covered member of your family will receive an Aetna Better Health member identification card (ID) card. Show this card every time you need health care. Carry this card with you at all times. Keep your card in a safe place. Do not let anyone else use your ID card. The state will also send you a card called the Medicaid identification card. Keep both your Aetna Better Health and state ID card with you at all times. 42

45 Your card will look like this: Your Aetna Better Health member ID card will include: Your member ID and state ID number Your name Your PCP s name and telephone number Your Aetna Better Health effective date Copayment information Your ID card shows the date you can start using your card and getting care from Aetna Better Health. You cannot get services through Aetna Better Health before this date. You will get an Aetna Better Health ID card when you join our health plan. If you need another ID card, please call Member Services at (TTY: 711 or TDD: ). We send new cards when: You request one You change or correct the spelling of a name Your card is lost or stolen You add a new member to your family You change your PCP Allow 7 10 working days to get your new ID card. 43

46 Member Services Section 4: Getting help Our Member Services staff is here to help you. They: Explain how Aetna Better Health works Help you learn about in network providers Help you choose a primary care provider (PCP) and explain how to get services from your PCP Help you find a specialty care provider/specialist Explain how to get behavioral health and substance use disorder services Explain how to get hospital services Explain how to get care when you are out of Aetna Better Health s service area Explain how to get care after normal office hours Explain how and when to get emergency care or use 911 services Help you if you receive a medical bill Explain your rights and responsibilities Explain your benefits and exclusions or limits, including out of network services Explain copayments Help you get appointments and transportation to medical visits Respond quickly to your questions Connect you to interpreter services if needed Give information about advance directives Help you voice a complaint or grievance Help you file an appeal and/or a state fair hearing Explain how Aetna Better Health evaluates new technology for inclusion as a covered benefit Help direct you to the state for information about pharmacy and dental benefits Call Member Services when you need help at (TTY: 711 or TDD: ). Communication/translation services We want to make sure you understand your benefits. Member Services can help if you: Have problems hearing (TTY: 711 or TDD: ) Have problems seeing other format available Have problems reading other format or interpreters available Do not speak English translated materials in Spanish are available 44

47 Interpreter services: If you do not speak or understand English call (TTY: 711 or TDD: ) to ask for help. We will get you an interpreter when needed We have this book in Spanish All Interpreter services are free Si usted no entiende Inglés, por favor llame al: (TTY: 711 o TDD: ) y nosotros le proveeremos la información acerca de sus beneficios en español. También podemos ayudarle a comunicarse con su médico. Este servicio es gratuito. 45

48 Foreign languages spoken at provider offices If you speak a language other than English, please check our provider directory for a provider who speaks your language. If you need a free provider directory, call Member Services at (TTY: 711 or TDD: ) and we will mail one to you. Or, go to for a provider list. You can also use the Provider Search on our Website for the most up to date provider information. Interpretation services are free. Aetna Better Health online You can find Aetna Better Health information and health related education material on the web. En nuestra página web puedes encontrar información sobre Aetna Better Health y materiales educativos relativas a la salud. Go to. This website gives you access to: Benefits and services and information on how to use them Your rights and responsibilities Information on our case management and disease management programs Special programs Member newsletters and other member materials Ted E. Bear, M.D. SM Kids Club Provider directories Tips on how to better manage your health and wellness, including recommended screenings for children and adults Health related topics for adults, adolescents and children How to contact us Secure member portal to check member eligibility and benefits, status of claim, status of prior authorization request and more. For more information, go to. 46

49 Case management program/disease management program You may have an ongoing illness, a history of health problems or problems following Aetna Better Health s rules for getting health care. Aetna Better Health wants to work with you and your provider to meet your health care needs. Case management helps you get the best care in the best way possible. Our nurses can help you make appointments. Our nurses can help you coordinate your health care needs. Aetna Better Health will follow state guidelines or nationally recognized guidelines for any care requested by your provider. Disease management programs help you take good care of yourself. These programs provide information about: Asthma High risk pregnancy Chronic renal failure Hypertension Congestive heart failure Low back pain Coronary artery disease Multiple sclerosis COPD Obesity Diabetes Sickle cell HIV/AIDS Call us if you need these services. Call us if you have special health care needs. For questions, call Member Services at (TTY: 711 or TDD: ). Ask Member Services to speak with a case manager or disease manager. If you do not want disease management or case management services, call Member Services at (TTY: 711 or TDD: ). Social worker services Aetna Better Health s social work staff connects you with community resources. We address problems that prevent you from getting, or staying, healthy. Social work services include: Education and support about Medicaid benefits Outreach to members with health conditions to connect them with providers and agencies that provide treatment and help Information and referrals to government and community support services. Examples: Referral to a shelter or safe house Information about Supplemental Nutrition Assistance Program (SNAP) nutrition assistance Food pantry and clothing donation resources 47

50 If you have a need, please call Member Services at (TTY: 711 or TDD: ). Satisfaction survey Aetna Better Health surveys members at least once a year. You may get a survey to fill out. The results are available to you. For a copy, please call Member Services at (TTY: 711 or TDD: ). 48

51 Section 5: Using your benefits Primary care provider (PCP) Your primary care provider (PCP) is your health care provider who takes care of all your main health care needs. You can choose your PCP. Your PCP will see you for well care checkups and medical problems. Your PCP is your medical home. A medical home helps make sure that the right medical care is available when you need it. Get to know your PCP. It helps ensure that you get medical care from someone who knows you and from someone who you feel comfortable with. Your PCP is your medical home. Your PCP takes care of all your main health care needs. If you have a new PCP, call your PCP and make an appointment, even if you are not sick. You can get to know each other. Your PCP will learn about your health to prevent or detect future illness. PCPs help keep you healthy by: Teaching you how to stay healthy Treating a health problem before it becomes serious Keeping immunizations up to date Providing care when you are sick Your PCP is available 24 hours a day, and 7 days a week. This includes holidays and weekends. If you need care after the office closes, call the PCP s office to find out how to get care after hours. If it is not an emergency, leave a message. If you still cannot reach your PCP, call the Informed Health Line at (TTY: 711). Your PCP s phone number is on your Aetna Better Health member ID card. You can change your PCP at any time by calling us at (TTY: 711 or TDD: ). There is no limit to the number of times you can change your PCP. If you need a free provider directory, call Member Services at (TTY: 711 or TDD: ) and we will mail one to you. Or, get one from our website at nebraska. Choosing and changing your primary care provider (PCP) When you select Aetna Better Health you must have an in network PCP. You may choose your PCP. If you do not, one is chosen for you. Your PCP will manage your health care. 49

52 Use the provider directory to pick a PCP in our network. PCPs include these providers: Family practice General practice Internal medicine Pediatrician Physician assistants Certified nurse midwives Certified registered nurse practitioners Medical residents You may choose a women s health specialist as your primary care provider. You can change your PCP at any time by calling Aetna Better Health at (TTY: 711 or TDD: ). There is no limit to the number of times you can change your PCP. You may ask for a specialist as your PCP if you have a chronic illness or special need. You may choose an Indian Health Service or tribal clinic provider as a PCP if you are a registered American Indian or Alaskan Native. Restricted services members will follow the state s PCP change process. If you need a free provider directory, call Member Services at (TTY: 711 or TDD: ) and we will mail one to you. Or, get one from our website at. Specialists Your PCP may arrange for services with specialty providers. He/she may give you a prescription or a note with the reason for your visit. Be sure to give this to the specialist. You do not need a referral form to see an in network specialty care provider/specialist. Always check with your PCP before you get care from a specialist. You must see providers in the Aetna Better Health provider network (in network) for all services other than emergency services, tribal clinics or Indian Health Services and family planning. Aetna Better Health s Pre Authorization department must approve all care from out of network specialists. If you have a special health condition, you may ask your specialist to act as your PCP. You or your provider should contact Member Services at (TTY: 711 or TDD: ) to make this request. The provider must agree to be your PCP. You can get regular well woman OB/GYN care without seeing your PCP first. You must get the services from an in network provider. You may get family planning services from any Medicaid participating family planning provider. You do not need a referral from Aetna Better Health or your PCP for this service. 50

53 If you need a free Provider Directory, call Member Services at (TTY: 711 or TDD: ) and we will mail one to you. Or, get one from our website at. Getting care It is important to know your options for medical care before you need care. It helps you get the right care at the right time and at the right place. Use the information below to help guide you to the right place of care for your medical needs. Remember to go to the emergency room only for true emergencies. Be sure to know the difference between a medical emergency and a situation where you should be seen by your primary care provider or an urgent care clinic. Primary care provider: If you have a cough, sore throat, rash, or other medical concern, you should see your PCP. Call your PCP to schedule an office visit. Your PCP should provide most of your care, including checkups and medical problems. Informed Health Line at (TTY: 711). Call the Informed Health Line if you cannot get in touch with your PCP. They will help you decide what to do next see your provider, go to an urgent care clinic or help you treat the problem at home. Urgent care clinics are a place you can go when you cannot see your PCP. They treat conditions that need immediate attention. These conditions are not life threatening. Urgent care clinics should NOT be used for routine care that can be scheduled with your PCP. The emergency room is for serious medical conditions. These conditions could result in permanent harm or death if not treated immediately. Emergency care should not be used for routine care that can be scheduled with your PCP. If you are not sure if you need emergency care, call your PCP or the Informed Health Line. If you need help making an appointment, call Member Services at (TTY: 711 or TDD: ) and we can help you. We can also help you schedule a ride to your medical appointments. Your PCP must see you within 14 days when you call for a regular health care appointment with your PCP. Call (TTY: 711 or TDD: ) if you need help. If you are pregnant, you have the right to see a health care provider sooner. In the first six months of pregnancy, you must be seen within seven days of calling for an appointment. In the last three months of your pregnancy, you must be seen within three days of calling for an appointment. 51

54 Second opinion You may want a second opinion about an illness or surgery to confirm the treatment or care your provider says you need. Contact your provider or Aetna Better Health Member Services at (TTY: 711 or TDD: ) for help to get a second opinion. There is no additional cost to you for the second opinion from an Aetna Better Health provider. You may have a copayment. Second opinions from an out of network provider require pre authorization from Aetna Better Health. Direct access to care You can get the following services from out of network providers without referral or pre authorization from Aetna Better Health: Emergency services Family planning Sexually transmitted disease services If you are an American Indian or Alaskan Native, you can receive services from a tribal clinic, Indian Health Services or any Aetna Better Health network provider without pre authorization. You may choose an Indian Health Service or tribal clinic provider as a PCP if you are a registered American Indian or Alaskan Native. If you have a chronic or severe illness, like HIV/AIDS, Aetna Better Health encourages you to talk with your PCP about all your care. You can go to any in network provider without a referral. Some services may require pre authorization. You can see a women s health specialist as your PCP. Family planning and treatment for STDs Family planning services and treatment of a sexually transmitted disease (STD) are professional services provided by your PCP or OB/GYN doctor. These services are kept private. You can access these services by going to any Nebraska Medicaid family planning provider or clinic. The provider can be in or out of the Aetna Better Health provider network. You don t need a referral. Just show your Aetna Better Health and Nebraska Medicaid ID cards. To pick a network provider or clinic, call Member Services or go to the provider directory on our website. You can access the following family planning services at no charge to you: Family planning exam Pap smear Gonorrhea and chlamydia cultures 52

55 Syphilis tests Pregnancy tests Rubella screen or immunization Breast exam Mammograms Human papilloma virus (HPV) vaccine Prescription and (OTC) birth control medication Birth control medical visits Education and counseling PCP in office visits Sterilization, tubal ligation and vasectomy. Members must meet age and consent requirements. Treatment of birth control use problems. This includes emergency services. Physical exams and lab tests Birth control ordered at a family planning visit Out of network providers Your provider must get permission for you to go out of network for all services except: Emergencies Family planning Treatment for STDs Tribal clinics Indian Health Services If Aetna Better Health cannot provide necessary, covered services for you in network, we will cover them out of network. We cover the services until we can provide them in network. Have your provider call (TTY: 711 or TDD: ). Medical help away from home We will pay for non emergency care out of the area only if: You call your PCP first and he or she says that it is important that you get care before you return home. The provider you see agrees to accept Nebraska Medicaid payment and they are a Nebraska Medicaid provider. Your PCP must then call Aetna Better Health to get approval. If you do not speak to your PCP before you get non emergency care when you are away from home, you may have to pay for the care yourself. If you cannot reach your PCP, please call Member Services. 53

56 This means if you or your family members are out of town and need non emergency care, Aetna Better Health will pay only if you get approval from Aetna Better Health first. If you need emergency care when you are out of town, go immediately to the emergency room (ER) at the nearest hospital. Call your PCP as soon as you can. Notice of changes Aetna Better Health mails you notices about any changes at least 30 days before benefits or our operations change. Aetna Better Health tells you at least 15 days in advance if your health care provider leaves our network. If your Nebraska Medicaid Managed Care benefits change or end, you are notified in writing. You may also call Member Services at (TTY: 711 or TDD: ) about benefit changes. Reporting fraud and abuse Committing fraud or abuse is against the law. Fraud is a dishonest act done on purpose. Examples of fraud are: Letting someone else use your Aetna Better Health ID card(s) or Getting prescriptions with the idea of abusing or selling drugs. An example of provider fraud is: Billing for services not provided. Abuse is an act that does not follow good practices. An example of member abuse is: Going to the emergency room for something that is not an emergency. An example of provider abuse is: Prescribing a more expensive item than is needed. You should report instances of fraud and abuse to: Aetna Better Health of Nebraska Fraud and Abuse Help Line at (TTY: 711 or TDD: ). 54

57 Section 6: Covered services and limits Copayments Some services require a copayment. A copayment is the part of the medical bill that you pay. A copayment is usually only a small amount of the cost of the service. Providers will ask you for the copayment amount at the time of your visit or when you get services. Some members 19 years old and over will have a copayment when they have certain medical services. Some members are not required to have a copayment. These are: Children 18 years and younger Pregnant women through 60 days after delivery Native Americans and Alaska Natives Members living in state defined living arrangements Many services do not have a copayment. Some of them are: Primary care provider (PCP) office visits Maternity Care Family planning services Emergency services/urgent care Immunizations Allergy services at your PCP office Sports and school physicals The copayments are: Service type Primary care provider (PCP) visits Durable medical equipment (for example, crutches and walkers) Eye glasses Hearing aids Inpatient hospital Optometric office visit (eye doctor) Outpatient hospital services (except radiology, lab and dialysis) Copayment amount $0 per visit $3 per specified item $2 per frame, lens, or frames with lenses $3 per hearing aid $15 per admission $2 per visit $3 per visit 55

58 Service type Specialist office visit (for example, cardiology, orthopedic, gastroenterology) Chiropractic office visit Podiatrist office visits (foot doctor) Physical therapy and occupational Therapy (non hospital based) Speech therapy (non hospital based) Copayment amount $2 per visit $1 per visit $1 per visit $1 per therapy $2 per specified therapy Frequently asked questions: Do children have copayments? No. Children age 18 and younger do not have copayments. What is a copayment? A small amount you pay when you have certain medical services. How do copayments work? Your provider will ask you to pay a small amount of the cost of the services when you receive care. There are no copayments in certain situations. In some situations you may receive a bill from your provider for the copay amount if not paid at time of visit. What if I can t afford the copayment? Copayments are part of your benefits, and are required to be paid. Your provider may bill you for the copayment if you are not able to pay at the time of service. Call Member Services at (TTY: 711 or TDD: ) if you have questions on your copayments. Pre authorization There are some services that require pre authorization from Aetna Better Health or the state before the care is provided. Most of the time, your PCP will order all care and will get any approval that is needed. Services may be approved for one diagnosis but not for others. All care that is received from a provider who is not in the Aetna Better Health network must be reviewed and approved before receiving the care. You or your provider must get permission to go out of network for all services except emergencies, family planning and treatment for STDs, tribal clinics and Indian Health Services. 56

59 Covered services, exclusions and limits SERVICE OR SUPPLY EXCLUSIONS OR LIMITS PRE AUTHORIZATION REQUIRED **The exclusions and limitations listed in this table are not meant to be a complete list. Please contact Member Services at (TTY: 711 or TDD: ) with coverage questions. Ambulance services No emergency Ambulance services non emergency Breast pumps Portable electric pumps and non portable hospital grade pumps available. Chiropractic services Diabetic education Pre authorization is needed for ambulance services that are not for emergency care. Please have your provider call IntelliRide at Local Omaha call (TTY: ) Written prescription needed from provider. Portable electric pumps: Limited to 1 per year. Non portable hospital grade (rented) pumps require pre authorization. Coverage is limited to manual treatment of the spine and one set of spinal x rays per year. Members under age 21 may get up to 25 treatments per benefit year. Members over age 21 may get up to 12 treatments per benefit year. Yes Yes for non portable hospital grade (rented) pumps No No 57

60 Covered services, exclusions and limits SERVICE OR SUPPLY Durable medical equipment (DME) and medical supplies Early and Periodic Screening, Diagnosis and Treatment (EPSDT) EXCLUSIONS OR LIMITS Items that are for convenience, are not medically needed, or are not ordered by a provider are not covered. Orthotics may not be covered for certain conditions. All children are given the care needed to promote health through the EPSDT Program. Under Aetna Better Health, children may be eligible to receive certain otherwise non covered services under EPSDT. EPSDT covers medically necessary services, which will cure an illness or condition or at least keep it from getting worse. PRE AUTHORIZATION REQUIRED Yes, for some equipment and supplies (including any rentals) No 58

61 Covered services, exclusions and limits SERVICE OR SUPPLY Eye care and eye glasses All services must be performed by a licensed Block Vision provider: optometrist or optician. Call Block Vision at (TTY: 711 or TDD: ). EXCLUSIONS OR LIMITS Exams: Members under age 21 may get 1 routine eye examination per year. Members over age 21 may get 1 routine eye examination every 2 years. Eye exercises (orthoptics) are limited to 22 sessions for members under age 21. Eye glasses: Members may get 1 pair of covered frames and lens in each 2 year period if certain guidelines are met. Any upgrades or add ons are not covered. Contact lenses for routine vision correction are not covered. PRE AUTHORIZATION REQUIRED No 59

62 Covered services, exclusions and limits SERVICE OR SUPPLY Family planning services and supplies Family planning services may be obtained from any Medicaid physician. Foot care EXCLUSIONS OR LIMITS Sterilization over the age 21 is covered only when: You request and sign a sterilization consent form at your provider s office. It has been 30 days since the sterilization consent form was signed at your provider s office. You are mentally competent Hysterectomies performed solely for the purpose of sterilization are not covered. Treatment of infertility or services to promote fertility is not covered. Abortions are not covered unless the life of the mother is threatened by carrying the fetus to term. House calls are only covered if you must stay in bed or if a trip to the foot provider would harm you. The number of routine foot care visits may be limited. Orthotics may not be covered for certain conditions. PRE AUTHORIZATION REQUIRED No No 60

63 Covered services, exclusions and limits SERVICE OR SUPPLY Hearing aids and services High risk prenatal and infant services Home health care EXCLUSIONS OR LIMITS For members age 20 and younger. There are no limits. For members age 21 and older: Hearing aids are limited to 1 aid per ear every 4 years. Hearing tests are covered. Non covered: Accessories that are for convenience or in the canal (ITC) or completely in the canal (CIC) hearing aids. Aetna Better Health s Healthy Mom, Happy Baby program provides case management for members at risk or who have complex or special health care needs. Please contact Member Services for limits. The care must be prescribed by your provider. Your provider must state that you are unable to receive the care at the hospital or at the provider s office. There are other limits to the services that may apply. PRE AUTHORIZATION REQUIRED Yes for cochlear implants Plan must be notified Yes 61

64 Covered services, exclusions and limits SERVICE OR SUPPLY Inpatient and outpatient hospital care Maternity care Please see your provider as soon as you know you are pregnant. Outpatient tests Physician services EXCLUSIONS OR LIMITS Items that are not covered: Any service that is not medically needed. Cosmetic surgery done only to make you look better. Convenience or comfort items. Private room when not medically needed. Two OB ultrasounds Infertility treatment is not covered. Planned home birth is not covered. Please have your provider notify Aetna Better Health once your pregnancy is confirmed. Paternity testing is not covered. Services for the treatment of infertility are not covered. Some tests need pre authorization. Physical one routine physical exam every 12 months when performed by your PCP. Sports and school physicals annually. PRE AUTHORIZATION REQUIRED Yes Yes for more than two OB ultrasounds Yes No 62

65 Covered services, exclusions and limits SERVICE OR SUPPLY Private duty nursing Radiology (X rays, MRIs, CT scans, PET scans) Reconstructive surgery Skilled nursing facility care EXCLUSIONS OR LIMITS Private duty nursing care in your home is covered. There is a limit to the number of hours that can be used for overnight nursing services and respite care. Pre authorization is needed for all private duty nursing. Work and school schedules may be requested. X rays are covered if they are ordered by a provider. Some radiology may need pre authorization. Any surgery that is performed only to make you look better and is determined to be cosmetic is not covered. Items that are not covered: Any service that is not medically needed. Convenience or comfort items. Private room when not medically needed. PRE AUTHORIZATION REQUIRED Yes Yes Yes Yes 63

66 Covered services, exclusions and limits SERVICE OR SUPPLY Sterilization services Therapy services (physical, speech, occupational, PT/OT/ST) EXCLUSIONS OR LIMITS Sterilizations (male and female) require completion of informed consent forms at least 30 days prior to the date of the procedure. Hysterectomies are not covered if: The sole purpose was to make the woman sterile. The woman is under the age of 21. The woman is legally not able to consent to the sterilization. There is a limit of 60 therapy sessions per benefit year for physical therapy, occupational therapy, and speech therapy services combined for members 21 and older. Non covered: Maintenance therapy Therapy for delays in speech that is not due to a specific disease or brain injury PRE AUTHORIZATION REQUIRED No Yes for members under 21 years of age. 64

67 Covered services, exclusions and limits SERVICE OR SUPPLY Tobacco cessation stop smoking program Transplants Urgent care EXCLUSIONS OR LIMITS Two stop smoking sessions per 12 month period are covered. A stop smoking session includes four visits with a medical provider or a tobacco cessation counselor. Certain medications, patches or gum to help you stop smoking are covered by Medicaid. Please call NMAP at for coverage questions. Any testing or provider visits for a transplant require approval before the services occur. You must receive all of your urgent care from your PCP or urgent care facility when you are in the service area. PRE AUTHORIZATION REQUIRED No Copayments are part of your benefits, and are required to be paid. Your provider may bill you for the copayment if you are not able to pay at the time of service. Call Member Services at (TTY: 711 or TDD: ) if you have questions on your copayments. Pre authorization There are some services that require pre authorization from Aetna Better Health or the state before the care is provided. Most of the time, your PCP will order all care and will get any approval that is needed. Services may be approved for one diagnosis but not for others. All care that is received from a provider who is not in the Aetna Better Health network must be reviewed and approved before receiving the care. You or your provider must get permission to go out of network for all services except Yes No 65

68 emergencies, family planning and treatment for STDs, tribal clinics and Indian Health Services. What if I get a bill? Call Member Services at (TTY: 711 or TDD: ) and they will help you. They may also ask you to send the bill to Aetna Better Health. Include a note with the member s name, Aetna Better Health member ID number and phone number. We may need to call you with questions. Be sure to include the medical reason you saw this provider. We also need to know if your PCP approved this care. Medicaid does not allow providers to bill members for covered services when Aetna Better Health s rules are followed. Aetna Better Health pays providers directly for all covered services of Nebraska Medicaid Managed Care. If you do receive a bill, please send it to: Aetna Better Health Attn: Member Services W. Dodge Road Omaha, NE You do not have to pay for covered services even if: The state does not pay Aetna Better Health Aetna Better Health does not pay your provider for Medicaid covered services Your provider s bill is more than Aetna Better Health pays Aetna Better Health cannot pay its bills If you choose to pay for a non covered service, your provider will have you sign a waiver form. You must agree in writing that you are responsible for paying before you get the service. You may be responsible to pay for part of other services. You may have to pay for services if: You have a copayment You choose to get medical services not covered by Nebraska Medicaid You go to an out of network provider without approval Aetna Better Health pays our providers through contract agreements. Other insurance You must tell Aetna Better Health immediately if you have any other health insurance. If your other health insurance is ending, call Aetna Better Health at (TTY: 711 or TDD: ) with the insurance information. 66

69 You must tell Aetna Better Health if you have been in an accident, hurt at work, or have had anything happen that may have caused you to get medical care that someone else may be responsible to pay. Aetna Better Health will not consider your claim until all other responsible parties have paid their share. Telehealth services Aetna Better Health may cover certain telehealth services. Aetna Better Health will direct you to a provider who will provide this service. Call Aetna Better Health Member Services at (TTY: 711 or TDD: ). New technologies Doctors and health care companies always develop new technology. This can include anything from a new procedure to a new way to use a device. Aetna Better Health has processes on how to review and judge new technologies. When we find out about new technology, we carefully review the latest information. We may also ask experts for their opinions. We compare the information with well known standards. We base all of our decisions on making sure you have the right care and services. Health survey Every new Aetna Better Health member will get a health survey call from Aetna Better Health. During this call you will be asked health questions. These questions will help us better serve you. Your answers are private. Our nurses use this information to provide you with health related education. This education material may be mailed to you about a specific condition you have. It may be general information in the form of our quarterly member newsletter. You may also get a call from an Aetna Better Health nurse. The goal of these materials and calls is to help you stay healthy. If you do not want a telephone health survey, call Member Services at (TTY: 711 or TDD: ). 67

70 Section 7: General services not covered Services not covered Aetna Better Health does not cover all conditions or services. For example: If you want to have a cosmetic procedure, such as an operation to improve your appearance, your plan will not pay for that. Your provider may want to do tests on your heart. Some of these tests may not be covered. Many medical services and tests have complicated names. It can be difficult to understand what will be covered and what will not. Call Member Services at (TTY: 711 or TDD: ) to ask if something will be covered. Services not covered by Aetna Better Health: Any health care not provided by a provider in our network (except emergency, family planning services, and Indian Health Services) Any care not covered by Nebraska Medicaid regulations (unless noted as a Aetna Better Health extra benefit) Any care covered by Medicaid but not through Aetna Better Health, such as mental health, pharmacy and dental services Any health service that is not medically necessary Any hospital services that are convenience/personal comfort, custodial or respite care, unless otherwise noted Autopsies Contact lenses, unless to treat eye disease Diagnostic and therapeutic services to achieve pregnancy Elective abortions and related services Experimental/investigational drugs, procedures or equipment Elective cosmetic surgery, supplies or treatments unless the surgery is to improve the functioning of a member, to correct a visible disfigurement that would affect the person s ability to obtain or hold employment; or post mastectomy breast reconstruction Orthopedic shoes or shoe corrections for flexible or congenital flat feet Services to lose weight such as support programs, meal replacements or nutritional supplements Services that you already have with workers compensation, Veteran s Administration or other programs or insurance Services that are not authorized by Aetna Better Health, if authorization is required If you have any questions whether a procedure is covered, please speak to your PCP or call Member Services at (TTY: 711 or TDD: ). 68

71 Section 8: Emergency services and urgent care Emergency and urgent care When an unexpected illness or injury occurs that could cause serious harm to Aetna Better Health members, the first choice should be the primary care provider (PCP). When this is not possible, there are other choices for care. It is important to recognize a true medical emergency and be familiar with other choices. What should I do for medical care that is urgent, but not an emergency? Call your PCP. Your PCP will have phone coverage 24 hours a day, 7 days a week. Your PCP will give you advice on what to do about your condition. You can also call the Informed Health Line at (TTY: 711 or TDD: ). You do not need permission from anyone to go to the emergency room. Urgent care Urgent Care is for an unexpected illness or injury, which is not life threatening but requires fast medical attention. After hours care facilities are available in some areas for medical conditions not considered a medical emergency. Examples of urgent care include: Most broken bones Minor cuts or burns Sprains Mild to moderate bleeding Examples of conditions that are NOT usually urgent or emergency care: Colds and flu Sore throat Sinus congestion Rash Headaches Toothache Medical emergency A medical emergency is a serious medical condition resulting from an injury or illness. Emergencies arise suddenly and unexpectedly. They require immediate care and treatment to avoid placing your health in serious harm. Examples of a medical emergency include: Chest pain Trouble breathing Unconsciousness (blacking out) Sudden onset of severe pain Poisoning Convulsions or seizures Severe cuts or burns Severe or unusual bleeding A serious accident Any vaginal bleeding in pregnancy What should I do in an emergency? Go immediately to the nearest emergency room at the nearest hospital. If you need help getting to an emergency room fast, use a telephone and dial the numbers 911 to reach the Emergency Telephone System. 911 calls are answered 6 to12 seconds after you call. In some cases, there is about 5 69

72 to 6 seconds of silence before you hear someone answer. Do not hang up. If you do not speak English, it is important you tell the operator what language you speak. The 911 operator must ask some questions to understand your situation and where it is happening. Stay on the telephone for as long as you can so the operator can get you help. The Nebraska Regional Poison Center telephone number is Make an appointment with your PCP for follow up care. If you have an emergency medical condition, you are not responsible for payment of later screenings and treatment needed to detect or stabilize the specific condition. If these services are requested and Aetna Better Health does not respond within one hour, cannot be reached, or Aetna Better Health and the physician treating you cannot reach agreement about your care, Aetna Better Health will pay for the services. For services not pre approved, Aetna Better Health will stop paying: Once your provider assumes your care, or If you are transferred to another place of service, or Once you are discharged, or When Aetna Better Health and the treating provider agree that you are stable enough to transfer or discharge. The attending emergency provider or the provider treating you is responsible for determining when you are stable enough to transfer or discharge. Aetna Better Health pays for services utilized to diagnose or treat a medical emergency. 70

73 Section 9: Routine screening, testing and cancer related checkups Wellness care for adults It is important to see your primary care provider (PCP) or OB/GYN for an annual physical. The purpose of an annual physical is to receive a physical exam and preventive screenings that may find health problems early. Annual physicals and preventive screenings are important because you may look healthy and feel well and still have a health problem. If you are pregnant, see your provider right away for prenatal care. Do not smoke, drink alcohol, or take any drugs not prescribed by your PCP. It is unhealthy for you and your baby. We can help you stay healthy through preventive services such as: Routine physicals every 12 months Preventive screenings such as pap smears, mammograms and colonoscopies Family planning services Immunizations (shots), except those required for travel Set up an appointment for a physical each year. Wellness care for children Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is a special health program that covers health screening and treatment for members age 20 and younger. The EPSDT program provides regularly scheduled health checkups with tests and shots that are right for your age. It also provides care for any health problems found during an EPSDT checkup. Routine EPSDT checkups are a good way to keep your child healthy. EPSDT checkups find and treat childhood health problems early. Regular EPSDT checkups are important because some Child/children may look healthy and feel well and still have a health problem. The EPSDT checkups include: Health history and physical exam, including school and sports physicals Hearing, vision and dental screening Necessary lab tests, including lead screenings Immunizations (shots) to help prevent illness, and Health education Set up an appointment for your child s health check with their PCP. 71

74 Well child visits Children should get checkups regularly. The first well child visit will be in the hospital when your baby is born. You must set up a well visit with your child s PCP when the child is: 3 5 days old 12 months old 1 month old 15 months old 2 months old 18 months old 4 months old 24 months old 6 months old 30 months old 9 months old Set up annual well child visits with your child s PCP beginning at the age of 3. Immunizations Immunizations (shots) are necessary to help the body fight disease. It is important for your child to get their shots on time. Children must have a record of these shots in order to begin school. You are required to provide a record of your child s shots when you enroll them in school. The chart below is the recommended immunization schedule for people aged 0 18 years from the Department of Health and Human Services Centers for Disease Control and Prevention. This chart can be used as a guide for you to help keep track of the shots your child needs. Immunization Record Age Immunization Date Received Birth Hep B 1 month Hep B 2 months DTaP, Hib, IPV, PCV, Rota 4 months DTaP, Hib, IPV, PCV, Rota 6 months Hep B, DTaP, Hib, IPV, PCV, Influenza, Rota 12 months Hib, PCV, MMR, Varicella, Hep A Series 15 months DTaP 4 6 years DTaP, IPV, MMR, Varicella years Tdap or Td, MCV, HPV (3 doses) years Tdap or Td, MCV, HPV series (catch up) Every year Influenza (after 6 months) 72

75 Section 10: Special programs Ted E. Bear, M.D. SM Kids Club Our Ted E. Bear, M.D. SM Kids Club is free to all Aetna Better Health children. Benefits are automatic and include: Paid membership to Boy Scouts of America Paid membership to Girl Scouts of the USA Birthday postcard during child s birthday month Member newsletter Kids Health information on our website Call Member Services for details about these benefits. Boy and Girl Scouts Girl Scouts of the USA and Boy Scouts of America Aetna Better Health pays the cost for an annual Girl Scout membership for all girls in K 12th grade. Aetna Better Health pays the cost for an annual Boy Scout membership for all youth ages 6 16 years old. As a bonus, Girl Scouts get to choose between a basic scout uniform, Journey book or the Girls Guide to Girl Scouts handbook after six months of scouting. Boy Scouts get the Boys Life magazine subscription each year they re a scout. Call Member Services at (TTY: 711 or TDD: ) or visit for an application to the Scouts clubs. Healthy living is not just about health care; it s about being active in your neighborhood and joining clubs like the Boy and Girl Scouts. Welcome to the club. Pregnancy programs Aetna Better Health has free pregnancy programs for you and your baby. Call Aetna Better Health at (TTY: 711 or TDD: ) when you find out that you are pregnant. Aetna Better Health is here to help you understand what you can do to make sure you have a healthy pregnancy. Look to Aetna Better Health for helpful health information and tools to keep you and your baby safe and healthy. Make an appointment with your PCP or OB when you find out that you are pregnant. One of the best ways to have a healthy child is to see your doctor 73

76 regularly during your pregnancy. Keeping your appointments helps the doctor make sure you and your baby are healthy and growing. Nurses to help you and your baby If you have special health care needs, you can be enrolled in Aetna Better Health s pregnancy program. The nurses help you throughout your pregnancy and after you deliver. They are available to talk on the phone. Our nurses will assist you in getting the health care services you need. The nurses also provide healthy eating, breastfeeding, exercise and baby care tips. They also have information to help with other services, like: Transportation The WIC (Women, Infants and Children) program Behavioral health and substance use disorders Domestic abuse support Breastfeeding support Helping you understand your emotions Aetna Better Health also has a NICU program for the parents or caregivers of a baby who need special medical care in a neonatal intensive care unit (NICU). Our nurses will work with you and your health care providers over the first 12 months of your baby s life to help achieve the best outcomes possible. Free portable crib Your baby should have her own bed at home. Accidental baby death due to rollover suffocation in the family bed is a tragedy. Protect your baby by giving him or her a safe place to sleep alone in the crib. Aetna Better Health can help with this. If you attend seven visits with your doctor during your pregnancy, we will give you a free portable crib for your baby. It s easy. See your doctor to keep you and your baby healthy. We will give a safe place for your baby to sleep. Childbirth education/parenting classes Aetna Better Health offers to pay the cost of childbirth education and parenting classes. Call (TTY: 711 or TDD: ) to see if your class is covered. Text4baby Text BABY to to receive free text messages each week. These messages give: Helpful pregnancy tips Facts about baby s development Information on health and nutrition while you are pregnant Tips on newborn care Information on breastfeeding Facts on important immunizations Reminders to make appointments and more 74

77 Postpartum gift for healthy moms We also want you to be healthy after your baby is born. See your doctor between 21 and 56 days after your baby arrives. This is the office visit after your baby is born. If your exam is between 21 and 56 days after your baby is born, you can get a $20 Walmart gift card. Aetna Better Health will send you a postpartum postcard. Ask your doctor to sign the card and mail to Aetna Better Health. This is a thank you for taking care of yourself. Please allow four to six weeks to get your Walmart gift card. Breast pumps Aetna Better Health wants to assist you in breastfeeding. As an extra benefit to our members, we will pay the cost of a portable electric breast pump. The portable electric breast pump will be yours to keep. You need to get a written prescription from your doctor. Give the prescription to any in network medical equipment company. If you have questions about breast pumps or need help finding an in network medical equipment company call our Member Services at (TTY: 711 or TDD: ). Non portable hospital grade breast pumps are available for rent if medically necessary. Please ask your health care provider if you think you need a hospital grade pump. Pregnancy packet We will mail you a pregnancy packet when we find out that you are pregnant. The packet will give you details about our special programs and tips on staying safe and healthy during your pregnancy. Contact our Member Services at (TTY: 711 or TDD: ) for questions about our pregnancy programs. Informed Health Line The Informed Health Line is a free nurse advice service. You can call (TTY: 711) and speak to a nurse 24 hours per day, 7 days per week. Nurses can answer questions when you or an enrolled family member is sick, hurt or you need medical advice. They also can help you decide whether to treat your problem at home, see your provider, go to the urgent care center or emergency room. Call the Informed Health Line to get help with questions about: Fever Earache/toothache Cuts and burns Vomiting Sore throat Colds and flu Medicines Bladder infection Pain Crying baby 75

78 The nurse will: Ask you about your problem Help you decide what to do Tell you what can be done at home to help you be more comfortable The nurse may even call you back to see how you are feeling 76

79 Section 11: Grievances and appeals Complaint, grievance and appeal procedures So that Aetna Better Health can meet your needs, we have set up complaint, grievance and appeal procedures. You may use the complaint, grievance and appeal procedures if: You do not agree with the way we interpret this handbook. The quality and speed of service does not meet your needs. You do not agree with our decision not to pre authorize care. You are not happy with your provider. You suspect Medicaid fraud or abuse. Complaint/grievance Complaints/grievances are when you call or send a letter to Aetna Better Health to tell us you are not happy with any part of your benefits, services or Aetna Better Health. If you: Do not agree with a decision made by Aetna Better Health Are not happy with any services received, or Are not happy about any other part of Aetna Better Health or your provider, you can file a complaint/grievance. You may do this by calling Aetna Better Health Member Services at (TTY: 711 or TDD: ) or writing it down and sending it to: Aetna Better Health Attn: Complaints & Grievances W. Dodge Road Omaha, NE By doing this, you are filing a complaint to tell us why you do not like a decision. You have 30 calendar days after the event you are unhappy about to file a complaint/grievance. If you need help in completing any forms or help with any other procedural steps to file a complaint/grievance, including interpreter services, please call (TTY: 711 or TDD: ). If you call Aetna Better Health Member Services at (TTY: 711 or TDD: ), we will take all of the information you give us and investigate the problem. We may ask for the following information: Your name Your Aetna Better Health member ID number Your date of birth Your provider s name 77

80 The date of service Your mailing address We will try to get you an answer in 15 working days. If that is not possible, you will get an answer in no longer than 30 working days from the date the complaint/grievance was filed. You will not be punished in any way for filing a complaint. If you have a complaint about non emergent transportation, please call IntelliRide at , extension 1003 (TTY: ). Appeal There may be times when Aetna Better Health says it will not pay at all or will not pay for part of a requested service. This is called an action. You may appeal an action. Aetna Better Health will send you a letter if we take any action to: Deny or give limited approval of a requested service Deny, reduce, suspend, or end a service that was already approved Deny payments for a service The letter is called a Notice of Action. The Notice of Action will tell you what we did and why. It will also explain your right to appeal or ask for a State Fair Hearing if you are unhappy with our action. You or someone else you approve can file an appeal: If you are not happy with our answer to your request, or If we have denied any part of your request for a health care service. You have a one level appeal process through Aetna Better Health. To file an appeal, or if you need help in completing any forms or help with any other procedural steps to file an appeal, including interpreter services, please call (TTY: 711 or TDD: ). You have 90 calendar days after the date we mail our Notice of Action to file an appeal. To file an appeal you will need to send us a written request with: Your name Your Aetna Better Health member ID number Your date of birth Your provider s name The date of service Your mailing address An explanation of why we should reverse our decision A copy of any information that will support your request, such as additional documents, records or information that would be helpful in your appeal 78

81 A written appeal should be mailed to: Aetna Better Health Appeals Coordinator West Dodge Road Omaha, NE You can file an appeal by calling Aetna Better Health. If you call to file the appeal you must also send Aetna Better Health your appeal in writing. Within three working days of our receipt we will send you a letter to: Confirm your appeal request. Tell you how you can get copies of documents, records and information about the Appeal at no charge. You must sign the letter and mail it back to Aetna Better Health for your appeal to continue. A committee will look at your appeal. None of the people on the Appeal Committee will have been involved in our initial decision to not pre authorize or cover the health services you are appealing. If your appeal involves a medical issue, the committee will include a health care professional who has the appropriate training and experience in the field of medicine necessary for making the decision on the medical issue. If your appeal is an administrative appeal (one not based on a medical issue), the Appeal Committee will consist of members of our senior management staff. You can come to the Appeal Committee meeting and talk to the Appeal Committee. In addition, you may ask a provider or someone you choose to represent you, to meet with the Appeal Committee with you, or in your place. If you decide to meet with the Appeal Committee and you need a special place to stay due to a disability, please call Aetna Better Health Member Services at (TTY: 711 or TDD: ). We will try to accommodate you while you are meeting with the Appeal Committee. An appeal should be resolved within 15 working days from the date Aetna Better Health receives it. If Aetna Better Health needs more time or more information for the appeal, or if you want to provide more information, you or Aetna Better Health can ask for 14 additional calendar days to finish the appeal. If Aetna Better Health needs more time or information for the appeal, you will be sent a written notice of the delay and the reasons for it before the 14th day. You will have the right to file a grievance if you disagree with the reason for the delay in the appeal decision. If you want to provide more information to Aetna Better Health regarding the appeal, you must request the extension before the 14th day. You have the right before and during the appeal process to examine your case file, including medical records and any other documents or records. Aetna Better Health does not punish your provider in any way for requesting a fast appeal or for supporting your request for a fast appeal. 79

82 Expedited (fast) appeals There is a fast appeal process to respond to cases where following the standard time limit could seriously harm your life or health. This is also called an expedited appeal. You have 90 calendar days after the date we mail our notice of action to file an expedited appeal. You have a one level expedited (fast) appeal process through Aetna Better Health. You may call Aetna Better Health Member Services at (TTY: 711 or TDD: ) for this type of appeal. If we allow the expedited (fast) appeal, Aetna Better Health will make a decision within 72 hours of the date listed on the Notice of Action. You may ask for another 14 calendar days to give more information. Aetna Better Health may also have a good reason for needing more information. We will send you a notice if there is a delay that you did not request. Aetna Better Health does not punish your provider in any way for requesting a fast appeal or for supporting your request for a fast appeal. You can come to the Appeal Committee meeting and talk to the appeal Committee. In addition, you may ask a provider or someone you choose to represent you, to meet with the Appeal Committee with you, or in your place. If you decide to meet with the Appeal Committee and you need a special place to stay due to a disability, please call Aetna Better Health Member Services at (TTY: 711 or TDD: ). We will try to accommodate you while you are meeting with the Appeal Committee. If we decide your appeal is not a fast appeal, we will handle your appeal like a regular appeal. You and your provider will receive a phone call or a letter letting you know that we will be following the normal appeal process. We will let you know what the normal appeal process time frames are when we call or send you and your provider the letter. State Fair Hearing process If you are not happy with Aetna Better Health s decision to deny, reduce, change or terminate payment for your health care services, you or anyone you choose can request a State Fair Hearing. The request must be within 90 days of the date on our Notice of Action. The request can be at the same time as, or instead of, appealing to Aetna Better Health. You have the right to participate in the State Fair Hearing or have a representative participate on your behalf. You will receive a notice from the Nebraska Department of Health and Human Services of the phone number to call to participate in the hearing. We will help you if you need it. 80

83 The state will make a decision within 90 days from the date you file the appeal for regular appeals. The state will decide within three working days for requests that meet the rules for an expedited (fast) appeal. Your request for a State Fair Hearing should be in writing and sent to: Nebraska Department of Health and Human Services Legal Services Hearing Section PO Box Lincoln, NE Your benefits during the appeal or State Fair Hearing process While your appeal or State Fair Hearing is in process, you may request that your Aetna Better Health benefits continue if: You or your provider files the appeal within 10 days of the date Aetna Better Health mailed the Notice of Action or the intended effective date of Aetna Better Health s proposed Action; and Your appeal is about our decision to terminate, suspend or reduce payment for a course of treatment that was already preauthorized; and The services were ordered by an authorized provider; and The authorization period has not expired; and You request in writing that your benefits be continued. If the final result of your appeal is to uphold the original decision to end, delay or limit the services and you continued to receive the services during the appeal or State Fair Hearing process, we could ask that you pay for those services. For help requesting a continuation of benefits, call Aetna Better Health Member Services at (TTY: 711 or TDD: ). Additional information available to you upon request: Information on the structure and operation of Aetna Better Health Physician incentive plans, if applicable Inquiries Oral or written inquiries can be about: The rules allowing you or a family member to get and keep Aetna Better Health coverage The health care services available to you as a Aetna Better Health member The rules Aetna Better Health has for you to get your health care services The handbook and other information Aetna Better Health sends to you Giving Aetna Better Health your new address if you move 81

84 PCP assignment Translation services List of available providers If you want to make an inquiry, call Aetna Better Health Member Services at (TTY: 711 or TDD: ). We will make every effort to respond to your inquiry on that phone call. If we cannot completely respond to your inquiry on the phone, we will call or write you back within 15 working days of the inquiry. If you want to write to Aetna Better Health, please send the information to: Aetna Better Health Attn: Inquiries & Complaints W. Dodge Road Omaha, NE

85 Section 12: Confidentiality and privacy Confidentiality and request for your medical records Aetna Better Health understands the importance of keeping your personal and health information secure and private. We are required by law to provide you with the Notice of Privacy Practices. This notice informs you of your rights about the privacy of your personal information and how we may use and share your personal information. Changes to this notice will apply to the information that we already have about you as well as any information that we may receive or create in the future. You may request a copy at any time. Both Aetna Better Health and your providers make sure that all member records are kept safe and private. Aetna Better Health will limit access to your personal information to those who need it. We maintain appropriate safeguards to protect it. For example, we protect access to our buildings and computer systems. Our Privacy Office also assures the training of our staff on our privacy and security policies. To properly service your benefits, we may use and share your personal information for treatment, payment and health care operations. We may limit the amount of information Aetna Better Health may share about you as required by law. For example, HIV/AIDS, substance abuse and genetic information may be further protected by law. Our privacy policies will always reflect the most protective laws that apply. In the provider s office, your medical record will be labeled with your identification and stored in a safe location in the office where other people cannot see your information. If your medical information is on a computer, there will be a special password needed to see that information. Your medical record cannot be sent to anyone else without your written permission, unless required by law. When you ask your provider s office to transfer records, they will give you a release form to sign. It is the responsibility of the office to do this service for you. If you have a problem getting your records or having them sent to another provider, please contact Aetna Better Health Member Services at (TTY: 711 or TDD: ). Below is a copy of your Aetna Better Health s Notice of Privacy Practices. Your privacy matters This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This notice takes effect on August 25,

86 What do we mean when we use the words health information? We use the words health information to mean information that identifies you. Examples include your: Name Date of birth Health care you received Amounts paid for your care How we use and share your health information Help take care of you: We may use your health information to help with your health care. We also use it to decide what services your benefits cover. We may tell you about services you can get. This could be checkups or medical tests. We may also remind you of appointments. We may share your health information with other people who give you care. This could be doctors or drug stores. If you are no longer with our plan, with your okay, we will give your health information to your new doctor. Family and friends: We may share your health information with someone who is helping you. They may be helping with your care or helping pay for your care. For example, if you have an accident, we may need to talk with one of these people. If you do not want us to give out your health information, call us. If you are under eighteen and don t want us to give your health information to your parents, call us. We can help in some cases if allowed by state law. For payment: We may give your health information to others who pay for your care. Your doctor must give us a claim form that includes your health information. We may also use your health information to look at the care your doctor gives you. We can also check your use of health services. Health care operations: We may use your health information to help us do our job. For example, we may use your health information for: Health promotion Case management Quality improvement Fraud prevention Disease prevention Legal matters A case manager may work with your doctor. They may tell you about programs or places that can help you with your health problem. When you call us with questions we need to look at your health information to give you answers. Sharing with other businesses We may share your health information with other businesses. We do this for the reasons we explained above. For example, you may have transportation covered in your plan. We may share your health information with them to 84

87 help you get to the doctor s office. We will tell them if you are in a motorized wheelchair so they send a van instead of a car to pick you up. Other reasons we might share your health information We also may share your health information for these reasons: Public safety To help with things like child abuse. Threats to public health. Research To researchers. After care is taken to protect your information. Business partners To people that provide services to us. They promise to keep your information safe. Industry regulation To state and federal agencies. They check us to make sure we are doing a good job. Law enforcement To federal, state and local enforcement people. Legal actions To courts for a lawsuit or legal matter. Reasons that we will need your written okay Except for what we explained above, we will ask for your okay before using or sharing your health information. For example, we will get your okay: For marketing reasons that have nothing to do with your health plan. Before sharing any psychotherapy notes. For the sale of your health information. For other reasons as required by law. You can cancel your okay at any time. To cancel your okay, write to us. We cannot use or share your genetic information when we make the decision to provide you health care insurance. What are your rights? You have the right to look at your health information. You can ask us for a copy of it. You can ask for your medical records. Call your doctor s office or the place where you were treated. You have the right to ask us to change your health information. You can ask us to change your health information if you think it is not right. If we don t agree with the change you asked for. Ask us to file a written statement of disagreement. You have the right to get a list of people or groups that we have shared your health information with. You have the right to ask for a private way to be in touch with you. If you think the way we keep in touch with you is not private enough, call us. We will do our best to be in touch with you in a way that is more private. You have the right to ask for special care in how we use or share your health information. We may use or share your health information in the ways we describe in this notice. 85

88 You can ask us not to use or share your information in these ways. This includes sharing with people involved in your health care. We don t have to agree. But, we will think about it carefully. You have the right to know if your health information was shared without your okay. We will tell you if we do this in a letter. Call us toll free at (TTY: 711 or TDD: ) to: Ask us to do any of the things above. Ask us for a paper copy of this notice. Ask us any questions about the notice. You also have the right to send us a complaint. If you think your rights were violated write to us at: W. Dodge Road Omaha, NE You also can file a complaint with the Department of Health and Human Services, Office of Civil Rights. Call us to get the address. If you are unhappy and tell the Office of Civil Rights, you will not lose plan membership or health care services. We will not use your complaint against you. Protecting your information We protect your health information with specific procedures. For example, we protect entry to our computers and buildings. This helps us to block unauthorized entry. We follow all state and federal laws for the protection of your health information. Will we change this notice? By law, we must keep your health information private. We must follow what we say in this notice. We also have the right to change this notice. If we change this notice, the changes apply to all of your information we have or will get in the future. You can get a copy of the most recent notice on our website at 86

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90 Index Definitions... 5 About your coverage...10 Extra Aetna Better Health benefits...10 Benefits available from the state...11 Communication/translation services...12 Foreign languages spoken at provider offices...13 Transportation...19 Your rights and responsibilities...36 Availability of care...39 Advance directives...40 Enrollment...41 Causes for disenrollment...41 Changes you need to report...42 ID cards...42 Member Services...44 Communication/translation services...44 Foreign languages spoken at provider offices...46 Aetna Better Health online...46 Case management program/disease management program...47 Social worker services...47 Satisfaction survey...48 Primary care provider (PCP)...49 Choosing and changing your primary care provider (PCP)...49 Specialists...50 Getting care...51 Second opinion...52 Direct access to care...52 Family planning and treatment for STDs...52 Out of network providers...53 Medical help away from home...53 Notice of changes...54 Reporting fraud and abuse...54 Copayments...55 Pre authorization...56 Pre authorization...65 What if I get a bill?...66 Other insurance...66 Telehealth services...67 New technologies...67 Health survey...67 Services not covered...68 Wellness care for adults...71 Wellness care for children

91 Ted E. Bear, M.D. SM Kids Club...73 Boy and Girl Scouts...73 Pregnancy programs...73 Informed Health Line...75 Complaint, grievance and appeal procedures...77 Complaint/grievance...77 Appeal...78 Expedited (fast) appeals...80 State Fair Hearing process...80 Your benefits during the appeal or State Fair Hearing process...81 Inquiries...81 Confidentiality and request for your medical records...83 Your privacy matters

92 Notes: 90

93 Notes: 91

94 Notes: 92

95 Nebraska Medicaid Managed Care Program Keep your Medicaid coverage! Open all of your mail from the state Medicaid agency immediately. Update your address with the state as soon as you move by calling ACCESSNebraska at (if in the Lincoln area, call ; if in the Omaha area, call ) or The United States Post Office may not forward your mail from the state. If you have enrollment questions, call the Medicaid Enrollment Center at (if in the Lincoln area call ).

96 Complete this checklist to start your track to good health New member checklist We want you to be healthy. This handbook teaches you how to make the most out of your benefits and services. Complete this list to get started. Read your Member Handbook. Always carry both your Aetna Better Health member ID card and your state Medicaid ID card with you. Your member ID card has important information like: Member Services and 24-Hour Nurse Line phone numbers Whether you have copayments for certain services Make an appointment with your primary care provider (PCP). If you did not choose a PCP, we assigned one for you. You can change your PCP at any time by calling Member Services. Make an appointment with your new PCP. Even if you are not sick, it gives you a chance to get to know each other. Complete our health survey. We will call you to learn about your health needs. Or we will send you questions in the mail if we cannot reach you. Report changes to ACCESSNebraska. You could lose your Medicaid coverage if the state cannot contact you. If you move or change your phone number, report your new information to ACCESSNebraska at (if in the Lincoln area, call ; if in the Omaha area, call ) or Read all mail from the state and Aetna Better Health. Return any phone messages from the state and Aetna Better Health. NE