- The Plan generally covers only medically necessary care and services.
- Inpatient hospital stays must be pre-certified for maximum benefit allowed by the Plan.
- The Medical POS II network of participating providers offers you savings in both time and money.
- Preventive care provisions help you stay healthy.
- The Plan offers you the opportunity to have your benefits determined before a procedure is performed.
For non-emergency medical care:
- If you are using a POS II network provider, or a mental health PPO network provider, your provider will handle the pre-certification process for you.
- Before you are admitted to a hospital that does not participate in the POS II or mental health PPO network, you must call Aetna for a medical pre-admission review or Magellan for a mental health confinement. This is required for most inpatient admissions, including extended-care facilities.
- You are not required to call to pre-certify:
- Hospitalization outside the United States, for both medical and mental health or substance abuse;
- Extended care facility.
- Skilled nursing care.
- Private duty nursing.
- Defibrillators and pacemakers not a result of emergency treatment.
- Heart catheterizations.
- Facility-based sleep studies.
- Cardiac rhythm implantable devices.
- Comprehensive infertility services and Advanced Reproductive Technologies (ART), including in-vitro fertilization (IVF), gamete intra-fallopian transfer (GIFT), zygote intra-fallopian transfer (ZIFT) and frozen embryo transfer (FET), which are only eligible if obtained at an Aetna-designated Institute of Excellence.
Enhanced clinical review:
The Plan also includes a utilization management program, known as Enhanced Clinical Review, of some diagnostic services (e.g., MRIs, CT Scans, Cardiac Imaging, sleep studies, hip/knee replacement procedures, etc.).
An enhanced clinical review is a mandatory review of select covered services that have equivalent, lower-cost alternatives, to ensure the higher cost service is medically necessary in advance of treatment. If the review is not completed and the treatment is not approved in advance, it will not be covered under the plan.
Please contact Aetna Member Services to determine if the service your physician has recommended requires enhanced clinical review.
For emergency inpatient admissions:
- If you are using a POS II network provider, your provider will obtain certification for you.
- You or someone acting on your behalf must call to certify care if you are in a non-network or out-of-network area hospital.
For mental health or substance abuse care:
For certain prescription drugs:
In some cases, you may be required to try one or more specified drugs to treat a particular medical condition before the plan will cover another (usually more expensive) drug
A pre-determination is an estimate of covered services and benefits payable in advance of treatment. It is not a guarantee of benefits eligible or payment amount. You may request a predetermination for any covered service. In most cases, you may receive an answer over the phone. In other cases, information from your provider may be needed. You or your doctor can also request a pre-determination of benefits, in writing, before the service is performed. Pre-determination is recommended for all outpatient surgical procedures.
This pre-determination may require review by one or more doctors. Be sure to allow time for this review between the pre-determination request and the proposed date of the service. By obtaining the written response, you will have more detailed information about the level of reimbursement.
For more information on requesting a predetermination, see the Information sources section at the front of this SPD.
- Primary participant's name and member ID, which can be found on your Aetna ID card;
- Patient's name;
- Complete description of medical services or surgical procedures. If possible, include the diagnosis code(s) and the five-digit Current Procedural Terminology (CPT) codes or the Healthcare Common Procedure Coding System (HCPCS) alpha-numeric codes, which you can get from the provider;
- Provider's complete information including name, address, zip code and phone number; and
- Provider's proposed fee for each service.
Medical POS II network
- Most office visits, diagnostic laboratory and X-ray work are reimbursed at 100%, unless related to surgery or emergency.
- Emergency room physician expenses, in-patient hospital, outpatient surgery or complex surgery are subject to deductible and coinsurance.
- Other expenses such as home health care, durable medical equipment or complex imaging are reimbursed at the network reimbursement level (either 80% for the POS II "B" or 75% for the POS II "A") of a negotiated rate after you meet the annual deductible.
- Your annual out-of-pocket maximum is significantly lower.
- Medical POS II network providers file claims and handle the hospital pre-admission review process for you.
- All negotiated charges are within reasonable and customary limits.
EMMP Medical POS II networks are located throughout the United States. As explained in the Introduction, the Medical POS II is part of the Aetna Choice® POS II network.
You are a network participant if you live in a Medical POS II area. These are some of the Medical POS II areas:
- Beaumont, Texas
- Baton Rouge, Louisiana
- Dallas, Texas
- Houston, Texas
If you or an eligible family member resides in a network area, you can use Aetna's Internet DocFind® (www.aetna.com/docfind) to locate providers in the area. ExxonMobil Me, the HR Intranet site, has a ZIP code search tool that identifies whether your home address ZIP code is located in an Aetna network area or in an out-of-network area.
Benefits Based on the Network Status of the Provider
- Check DocFind® (www.aetna.com/docfind) on Aetna's Web site for the most up-to-date list of Choice® POS II providers. The site is updated six times a week, excluding holidays, Sundays or during interruptions due to system maintenance, upgrades or unplanned outages. Before your appointment, confirm with Aetna Member Services, DocFind®, or the doctor’s office whether the doctor participates in the network, because network participation may change.
- Call Aetna Member Services for help with locating a POS II network provider.
Co-payment for office visits/lab work when provided by a primary care physician; higher co-payment when provided by a specialist.
Is your doctor a network provider?
Show your ID card
If you live in a medical POS II network area and do not use medical POS II network providers
- Your out-of-pocket costs will generally be higher. The Plan's reimbursement level is 60% for the POS II "B" and 55% for the POS II "A" of reasonable and customary charges, after you satisfy the deductible.
- You must call Aetna to initiate the medical pre-admission review process for inpatient treatment.
- If your provider's charges are above reasonable and customary limits, you are responsible for paying any amounts above reasonable and customary limits. You may be balance billed by the provider for any amount not reimbursed by Aetna.
- You are responsible for submitting claims.
An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson (including the parent of a minor child or the guardian of a disabled individual), who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
- Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
- Serious impairment to bodily function; or
- Serious dysfunction of any bodily organ or part.
Some examples of emergencies are:
- Heart attack or suspected heart attack
- Uncontrolled or severe bleeding.
- Suspected overdose of medication.
- Severe burns.
- High fever (especially in infants).
- Loss of consciousness.
Some common examples of non-emergencies are:
- Ear Infections
- Colds and Flu
Reimbursement for emergency services
Reimbursement for non-emergency services
If you go to a non-network emergency room and your condition is determined to be non-emergency, then the expense may be subject to the non-network level of reimbursement (either 60% for the POS II "B" or 55% for the POS II "A"), after the plan year deductible has been satisfied
Your physician may direct you to an Urgent Care Center as an alternative to a hospital emergency room when he or she feels it is appropriate to do so. If you or a family member receive care at a network urgent care center, you will pay the applicable co-pay, equal to the specialist physician co-pay under your plan option, and the plan pays the remaining charges. If you live in a network area, and you use a non-network urgent care center, you will be reimbursed at the non-network level (either 60% for the POS II "B" or 55% for the POS II "A"), after the plan year deductible has been satisfied. If you live in an out of network area, you will be reimbursed at the out of network area level (either 80% for the POS II "B" or 75% for the POS II "A") after you have met your deductible.
Care while traveling
If you live outside a medical POS II network area
If you incur claims outside of the U.S., reimbursement is paid at either 80% for the POS "B" or 75% for the "POS A" of billed charges after deductible. There is no reasonable and customary profiling for foreign providers.
If a covered family member lives away from home
If you live in a Medical POS II network area and you have a covered family member who lives away from home (for instance, you have a child away at school), your family member's ZIP code determines the level of benefits the Plan pays.
Call Aetna Member Services with your family member's ZIP code to find out if Aetna has a Choice® POS II network in the area. If a network is there, you can contact Aetna Member Services or use the Internet DocFind to identify providers in the area. Here is how benefits are determined:
- If your family member receives care from a network provider, benefits will be paid at the network level.
- If your family member lives in a Medical POS II network area but uses non-network providers, benefits are paid at the non-network level.
- If your family member lives in an area where the Medical POS II network is not available and receives care from a non-network provider, benefits are paid at the out-of-network area level — regardless of whether you live in a network or non-network area — if you have notified Aetna of your family member's address.
Upon request, Aetna Member Services will provide an identification card for your family member.
Because the Plan is a Grandfathered Plan, only certain preventive care services will be covered at 100%. If you use a non-network provider or live in a location where there is not a Medical POS II network, reasonable and customary charges for covered preventive care services will continue to apply. Preventive care services covered at 100% include the following:
- Routine Immunizations
- Prostate-Specific Antigen Test (PSA)
- Digital Rectal Examination (DRE)
- Routine Adult Physical
- Routine Mammography
- Routine GYN Exam
- Routine Well Baby Exam (includes hearing exam if under age seven)
- Routine Well Child Exam (includes hearing exam if under age seven)
- Colorectal Cancer Screening
- Double Barium Enema
- Fecal Occult
To receive preventive care benefits, the doctor's bill must indicate that the service is preventive in nature. If you are found to have a condition requiring additional treatment, the additional covered services will be paid after you meet any remaining annual deductible.