If you need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the world. Aetna has adopted the following definition of an emergency medical condition from the Balanced Budget Act (BBA) of 1997:
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.
- Severe shortness of breath.
- Uncontrolled or severe bleeding.
- Suspected overdose of medication.
- Severe burns.
- High fever (especially in infants).
- Loss of consciousness.
For both medical and mental health/substance abuse emergencies, whether you are in or out of Aetna’s or Magellan’s service areas respectively, we ask that you follow the guidelines below when you believe you may need emergency care.
- Call your PCP first, if possible (in the case of mental health and substance abuse emergency care participants should call the Magellan telephone number on their ID card as soon as reasonably possible and a clinical care manager will assist with next steps). Your PCP is required to provide urgent care and emergency coverage 24 hours a day, including weekends and holidays. However, if a delay would be detrimental to your health, seek the nearest emergency facility, or dial 911 or your local emergency response service.
- After assessing and stabilizing your condition, the emergency facility should contact your PCP so they can assist the treating physician by supplying information about your medical history.
- If you are admitted to an inpatient facility, notify your PCP as soon as reasonably possible. The emergency room co-payment will be waived if you are admitted to the hospital.
- All follow-up care must be coordinated by your PCP.
- If you go to an emergency facility for treatment that Aetna determines is non-emergency in nature, you will be responsible for the bill. The Plan does not cover non-emergency use of the emergency room.
Follow-up care after emergencies
All follow-up care should be coordinated by your PCP. You must have a referral from your PCP and approval from Aetna to receive follow-up care from a nonparticipating provider. Whether you were treated inside or outside your Aetna service area, you must obtain a referral before any follow-up care can be covered. Suture removal, cast removal, X-rays, and clinic and emergency room revisits are some examples of follow-up care.
Treatment that you obtain outside of your service area for an urgent medical condition is covered if:
- The service is a covered benefit;
- You could not reasonably have anticipated the need for the care prior to leaving the network service area; and
- A delay in receiving care until you could return and obtain care from a participating network provider would have caused serious deterioration in your health.
Aetna has adopted the following definition of urgent medical condition:
Urgent medical condition – means a medical condition for which care is medically necessary and immediately required because of unforeseen illness, injury or condition, and it is not reasonable, given the circumstances, to delay care in order to obtain the services through your home service area or from your PCP.
Some examples of urgent medical conditions are:
- Severe vomiting.
- Sore throat.
Follow-up care provided by your PCP is covered, subject to the office visit co-payment. Other follow-up care by participating specialists is fully covered with a prior written or electronic referral from your PCP, subject to the specialist co-pay shown in the “Co-payment Schedule.” If you are in your service area, you must use a participating urgent care center.
What to do outside your Aetna service area
If a participant goes to a hospital emergency room for an emergency, any provider can be utilized (preferred or non-preferred) and the emergency room co-pay will apply. Aetna Select allows participants to visit any Aetna network provider regardless of service area.
For urgent care, if you are out of your service area, participants can use a non-network urgent care provider or go to an emergency room. Non-emergency or non-urgent use of an urgent care provider is not covered. Urgent care may be obtained from a walk-in clinic, or an urgent care center. An urgent medical condition that occurs outside your Aetna service area can be treated in any of the above settings.
If, after reviewing information submitted to Aetna by the provider(s) who supplied your care, the nature of the urgent or emergency problem does not clearly qualify for coverage, it may be necessary to provide additional information.