Q. What types of medical services are covered by the Plan?
A. For plan purposes, all covered expenses must be medically necessary and not excluded. Generally Aetna's Clinical Policy Bulletins (CPBs) are relied upon to ensure consistent determination of coverage under the Medical Plan. Aetna's CPB's may be viewed online at www.aetna.com.
Covered expenses (EMMP POS II "A" and "B")
Some of the services covered by the Plan are listed below. Services not listed as a covered expense are excluded. If you do not see your procedure or treatment listed below, please contact Aetna Member Services listed in the Information sources section of this SPD to confirm coverage for the expense.
- Acupuncture if performed by a physician.
- Ambulatory surgical center, care, or services. An ambulatory surgical center:
- Is established, equipped and operated in accordance with applicable local laws primarily for the purpose of performing surgical procedures;
- Is operated under the full-time supervision of a licensed doctor of medicine or doctor of osteopathy;
- Permits a surgical procedure to be performed only by a duly qualified physician who, at the time the procedure is performed, has admitting privileges in at least one hospital to perform such a procedure;
- Has at least two operating rooms and at least one post-anesthesia recovery room, is equipped to perform x-ray and laboratory examinations, and has available trained personnel and necessary equipment, including a defibrillator, a tracheotomy set, and a blood supply, to handle foreseeable emergencies;
- Provides the full-time services of one or more registered graduate nurses for patient care in operating rooms and in the post-anesthesia recovery room;
- Maintains a written agreement with at least one hospital in the area for immediate acceptance of patients who develop complications or require post-operative confinement; and
- Maintains appropriate medical records for each patient.
- Braces, crutches and prostheses required because of an injury or disease. Coverage is generally limited to the purchase price.
- Chiropractic services, performed by a licensed doctor of chiropractic who is acting within the scope of his or her license, up to $1,000 per person per year (benefits paid for acupuncture and supplies billed by a doctor of chiropractic are not included in the $1,000 annual maximum).
- Dental work required by an accidental injury to sound, natural teeth or the mouth. Also, certain cutting procedures in the mouth. (See Dental treatment in Specific coverage below).
- Diagnosis and treatment of the underlying medical cause of infertility, but Comprehensive Infertility Services and Advanced Reproductive Technologies (ART) are not covered unless obtained at an Aetna-designated Institute of Excellence and pre-certified. ART services are subject to the $10,000 lifetime max. Diagnosis and treatment of the cause of infertility are covered as long as they are done at a participating infertility provider, facility or lab.
- Doctor visits at home, a hospital or an office, including emergency room care.
- Drugs and medicines obtainable only with a physician's prescription and approved by the U.S. Food and Drug Administration for the specific diagnosis.
- Durable medical equipment purchase, rental, repair or replacement. Most durable medical equipment is limited to rental up to the purchase price of the equipment. Durable medical equipment includes items such as wheelchairs, hospital beds, mechanical ventilators, and equipment for administering oxygen. A pre-determination is recommended.
- Extended Care Facility when pre-certified. (See Extended-care facility in the Specific coverage section below.)
- Gender reassignment surgery consistent with Aetna's clinical policy bulletins.
- Hearing aids. (See Hearing aids in the Specific coverage section below for more details).
- Home health aides, when pre-certified by Aetna, to provide individualized, non-custodial home care
- Hospice care when pre-certified. (Reference the Aetna National Precertification list for more details).
- Hospital emergency room care, including surgical care and other related charges.
- Hospital semi-private room and board, x-ray and pharmacy, tests and other medical supplies and services received in a hospital.
- Inpatient services performed by surgeons, anesthesiologists, and other physicians.
- Insulin and diabetic supplies received in a doctor's office or an outpatient setting are covered medical expenses. Insulin and diabetic supplies obtained in a retail setting, such as a pharmacy or those obtained by mail order, are covered by Express Scripts.
- Immunizations/vaccinations obtained outside of a physician's office or hospital.
- Morbid obesity (generally 100% or more over ideal body weight) treatments including physician expenses for the initial office visit and laboratory costs. Contact Aetna Member Services for guidelines regarding eligibility and approved programs for this coverage.
- Network mental health and substance abuse treatment (both inpatient and outpatient) and non-network mental health and substance abuse treatment (both inpatient and outpatient).
- Nutritional counseling performed by a licensed nutritionist for anorexia nervosa, bulimia nervosa and after bariatric surgery consistent with Claims Processor's internal clinical policy bulletins.
- Oral-motor therapy ordered by a physician for treatment of dysphagia or hypotonia.
- Outpatient medical tests and surgery.
- Physical therapy or occupational therapy for treatment of illness, injury or disease, which is performed by a licensed physical or occupational therapist who is acting within the scope of his or her license. If you or your provider anticipates that your current course of therapy may exceed 25 visits, have your physician or therapist submit medical records with each physical therapy claim. Claims for therapy services beyond the 25th visit are subject to medical review. Additional information will be required. Claims will not be paid if the service is found to not be medically necessary.
- Prescription smoking deterrent medications.
- Preventive care services. (See Medical POS II network in the Basic Plan features section for details).
- Private-duty nursing care rendered by a nurse when furnished outside of a hospital if such care requires a nurse's services and it is determined that such services are neither primarily custodial in nature nor could be provided by a person other than a nurse.
- Professional emergency transportation services. The Plan pays for medically necessary trips to or from the nearest facility capable of handling the situation. In addition, the Plan pays for transportation to the nearest POS II network facility once the patient is stabilized in a non-network facility.
- Reconstructive surgery including, but not limited to, surgery required because of a mastectomy. The Plan pays benefits for:
- Reconstructive surgery of the breast on which the surgery was performed.
- Reconstructive surgery of the other breast in order to produce symmetry.
- Prostheses for physical complications of mastectomy.
- Services related to the pregnancy of a covered child, but not those related to the child born to the family member.
- Medically necessary procedures to diagnose autism. The treatment of autism spectrum disorder is not covered under the Plan.
- Skilled-nursing care when pre-certified. (See Skilled-nursing care in Specific coverage in the Covered Expenses section below for details).
- Speech therapy, on an outpatient basis, to:
- Restore speech after a demonstrated previous ability to speak is lost or impaired;
- Improve or develop speech after surgery to correct a birth defect which impaired or would have impaired the ability to speak; or
- Improve or develop speech lost or impaired by an irreversible and permanent profound hearing loss resulting from a birth defect. (See Speech Therapy under Exclusions. Submission of a proposed treatment plan for a benefit pre-determination is strongly recommended.)
- Sterilization procedures.
- Treatment of temporomandibular disorders, sometimes referred to as "TMJ/TMD," including splints and orthotics. Pre-determination of benefits is strongly recommended.
- Telemedicine is a covered medical expense under all of the following conditions:
- it must be an interaction between a healthcare professional and a covered person via real-time audio-video technology, the originating site must be a physician’s or mental health provider’s office, a hospital, or a health clinic (e.g., not a residence, personal office or a retail pharmacy), it must consist of "face-toface" interactive video consultation services wherein the covered person is present, and it must exclude store-and-forward applications, such as teleradiology and remote EKG applications.
- Vision examinations and eyeglasses or contact lenses needed because of injury or disease.
- Vision therapy by a physician for amblyopia and strabismus up to a maximum of 32 vision therapy visits or sessions.
Comprehensive Infertility services, such as artificial insemination and ovulation induction, as well as Advanced Reproductive Technologies (ART), including in-vitro fertilization (IVF), gamete intra-fallopian transfer (GIFT), zygote intra-fallopian transfer (ZIFT) and frozen embryo transfer (FET), will be covered if obtained at Aetna-designated Institutes of Excellence (IOEs) and pre-certified by calling the National Infertility Unit at 1-800-575-5999. Coverage for this benefit is subject to a $10,000 lifetime limit for each covered person. Comprehensive infertility services are limited to six cycles of each per lifetime; charges for these cycles do not count toward the $10,000 lifetime limit.
Certain dental expenses are covered under the EMMP POS II "A" and "B" options. These include charges by a dentist or oral surgeon for treating fractures or dislocations of the jaw or for treating teeth and surrounding tissue damaged because of an injury sustained. Also covered are certain cutting procedures in the mouth, including:
- Impacted and unerupted teeth.
- Removing a tumor.
- Removing or draining an abcess or cyst.
- The alveolar process (alveoplasty and vestibuloplasty).
Oral surgery and related procedures covered under the POS II plan are reimbursed at 75% for the POS II “A” and 80% for the POS II “B”, regardless of the provider’s network participation.
For a complete list of oral surgery procedures which may also be considered for payment under the ExxonMobil Dental Plan, consult the ExxonMobil Dental Plan SPD. If you incur dental expenses that may be covered under this option, submit your claim to Aetna Member Services.
After determining benefits payable under this option, the claim will be processed as a dental claim (for coordination of benefits) for participants in the ExxonMobil Dental Plan. If you are not a participant in the ExxonMobil Dental Plan, when you receive an explanation of benefits, send the explanation and a copy of your bills along with a claim form to your other dental plan claims office.
An extended-care facility provides skilled-nursing services and rehabilitation care. Extended-care facility charges are covered expenses if these conditions are met:
- The confinement must be medically necessary, and
- The confinement has been pre-certified.
Reimbursement is based on the facility charge or daily room and board rate of the hospital from which the patient transferred, whichever is less.
Skilled-nursing care is covered if medically necessary and pre-certified. Nursing care that helps a person meet personal needs and daily living activities, such as bathing, dressing, eating or administering oral medication, even if ordered by a physician and performed by a licensed medical professional, is considered custodial and is not a covered expense eligible for benefits. Also, charges for a private-duty nurse in a hospital or an extended-care facility are not covered.
Skilled care involves nursing or rehabilitation services that can be provided only by licensed medical professionals. For example, intravenous feeding is a skilled service.
Benefits are provided up to a maximum of $2,500 after the deductible and co-insurance are paid for one or more medically necessary hearing aids every rolling five year period, which also includes the repair of a hearing aid. However, shipping and handling charges and routine maintenance such as battery replacement are not covered. The amount allowed is subject to reasonable and customary limits but not negotiated rates. There are no Medical POS II preferred providers for hearing aids and related materials. The member will be responsible for the difference between the billed and allowable amount regardless of provider participation.
You may be able to maximize your benefit through the Amplifon Hearing Health Care (formerly HearPo) or the Hearing Care Solutions Discount Program. These programs are available to Aetna participants and offer discounts on hearing exams, services and hearing aids. If you go to a participating hearing discount center, your out-of pocket expenses could be lower. To find a participating hearing discount center location, you can visit www.aetna.com and search DocFind®, or you can log in to Aetna Navigator® and click on “Find a Doctor, Facility or Pharmacy” and then select “Hearing Discount Locations”. To compare costs, please call Amplifon Hearing Health Care at 1-888-HEARING (1-888-432-7464) or Hearing Care Solutions at 1-866-344-7756 and identify yourself as an Aetna member.
Organ, tissue and bone marrow transplants
Aetna's National Medical Excellence® Program (NME Program) coordinates all aspects of organ, tissue, and bone marrow transplants and other complex specialized care. Providers in this program are recognized as centers of excellence with demonstrated improved outcomes in their area of expertise. In addition, if travel over 100 miles is required, lodging and meals for the patient and a traveling companion will be covered. The NME Program is separate and distinct from the Centers of Excellence described in the Culture of Health section of this SPD.
The NME Program is available on a voluntary basis. Contact Aetna Member Services for information.
Case management alternative treatment program
If as a result of a catastrophic or chronic illness or injury or in conjunction with certain organ transplant procedures, a participant proposes an alternative course of treatment, the Administrator-Benefits may waive any exclusion or limitation under the Plan which would otherwise apply to covered medical expenses, the reimbursable portions of covered medical expenses or out of pocket limits if such waiver would result in overall cost savings to the Plan. The review will include factors such as the efficacy of the proposed treatment, the patient's condition, availability and efficacy of other treatments that are approved for the patient's diagnosis, and the prior use of appropriate treatments for the condition. Such approval must be prior to the participant commencing the alternative course of treatment.
Treatment of last resort
In life-threatening situations, experimental or investigational treatment may be considered a covered expense as a treatment of last resort. A person's condition is considered life-threatening if there is a reasonable likelihood that death will result in a matter of months without treatment or that premature death will occur without early treatment. In this case, proposed experimental or investigational treatments will be reviewed by a panel of specialty-matched experts. The review will include factors such as the efficacy of the proposed treatment, the patient's condition, availability and efficacy of other treatments that are approved for the patient's diagnosis, and the prior use of appropriate treatments for the condition.
Treatment of last resort must be authorized by the Administrator-Benefits, and will be based on the fact that the covered person's condition is life-threatening and the treatment is recommended by a panel of specialty-matched physicians chosen to review the treatment.