Dual Preferred (HMO Plan) Members

Aetna Better Health of Ohio Dual Preferred (HMO Plan) is available to people who have Medicare and who receive Medicaid assistance. Aetna Better Health of Ohio Dual Preferred (HMO Plan) is a Medicare Special Needs Plan, which means our plan benefits and services are designed for people with special health care needs. Our plan offers additional benefits and services not covered under Medicare, such as dental, hearing aids, and eyewear. If you are a member of Aetna Better Health and enroll in the Aetna Better Health of Ohio Dual Preferred (HMO Plan) we will coordinate your Medicare and Medicaid covered services for you. 

For information, call Member Services at 1-800-260-3166 (TTY: 711) 8 a.m. to 8 p.m., 7 days a week.

Getting care when you need it

If the Governor of your state, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in your geographic area, you are still entitled to care from your plan.

For more information about the getting care during a disaster, refer to Chapter 3, Section 3 of Evidence of Coverage.

If you choose to go to a provider outside of our network without a referral from your PCP or prior authorization from the plan, you must pay for these services yourself except in limited situations (for example, emergency care or for urgently needed services or dialysis services when traveling outside of the plan service area ). Neither the plan nor traditional Medicare will pay for these services.

If you need medical care that Medicare or Medicaid requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You must obtain prior authorization before seeing an out-of-network provider. In this situation, we will cover these services as if you got the care from a network provider.

For information about getting approval to see an out-of-network provider, please contact Member Services at 1-800-260-3166 (TTY: 711) 8 a.m. to 8 p.m., 7 days a week. Calls to this number are free.

For more information on getting care from out-of-network providers, refer to Chapter 3, Section 2.4 of the Evidence of Coverage.

If you need help with a grievance, coverage decision or appeal, you can ask someone to act on your behalf by naming another person to act for you as your "representative." To give a friend, relative, your doctor or other provider, or other person the right to be your representative, call Member Services at 1-800-260-3166 (TTY: 711) 8 a.m. to 8 p.m., 7 days a week, and ask for the Appointment of Representative form. You also can download and print a copy of the Appointment of Representative form.

The form must be signed by you and by the person whom you would like to act on your behalf. The completed and signed form is valid for one (1) year.

If your representative holds durable power of attorney or guardianship papers, an Appointment of Representative form is not required.

Whether you are looking for help around your home, finding social activities around your community, or you are a caregiver looking for support, Aetna’s Resources for Living Program can help you find those resources. Click here to learn more about the Resources for Living Program.

The Centers for Medicare & Medicaid Services (CMS) sometimes change the coverage rules that apply to an item or service covered under Medicare and through your health plan that provides Medicare benefits. When these rules are changed, CMS issues a National Coverage Determination (NCD) and we are required to notify you of this information.

An NCD tells us:

  • What rule is changing
  • If Medicare will pay for an item or service
  • What item or service is covered

What does this mean to me?

We want you to be aware of any new NCDs that may affect your coverage. But new rules do not affect all members.

National Coverage Determination notices

This is effective for service on or after March 16, 2018

The Centers for Medicare & Medicaid Services (CMS) reviewed the evidence for laboratory diagnostic tests using NGS in patients with cancer. They determined that some tests could improve health outcomes for Medicare beneficiaries with advanced cancer.  Testing will be covered for beneficiaries with:

  • recurrent, relapsed, refractory or metastatic cancer
  • advanced stages III or IV cancer if the beneficiary either:
    • has not been previously tested using the same NGS test for the same primary diagnosis of cancer or
    • will get repeat testing using the same NGS test only when the treating physician gives a new primary cancer diagnosis and there will be further cancer treatment (e.g., therapeutic chemotherapy)

The test must be ordered by the treating physician, performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, and have all of the following requirements met:

  • Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and,
  • an FDA-approved or -cleared indication for use in that patient’s cancer; and,
  • results provided to the treating physician for management of the patient using a report template to specify treatment options

This summarizes CMS transmittal R210NCD

This is effective for service on or after April 3, 2017

Local Medicare administrators will decide if they'll cover topical oxygen for the treatment of chronic non-healing wounds.

This summarizes CMS transmittal R203NCD

This is effective for service on or after April 10, 2018.

CMS determined that MRI for Medicare beneficiaries with the below devices is reasonable and necessary under certain circumstances.

  • Implanted Pacemaker (PM)
  • Implantable Cardioverter Defibrillator (ICD)
  • Cardiac Resynchronization Therapy Pacemaker (CRT-P)
  • Cardiac Resynchronization Therapy Defibrillator (CRT-D)

CMS will expand coverage:

  • to include CRT-P or CRT-D devices
  • for beneficiaries who have an implanted FDA-approved, ICD, CRT-P, or CRT-D
  • for beneficiaries with an implanted PM, ICD, CRT-P, or CRT-D device without FDA labeling specific to use in an MRI environment if certain conditions are met

CMS will also remove the Coverage with Evidence Development (CED) requirement.

This summarizes CMS transmittal 208.

This affects services given on or after January 27, 2016
Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD's) that affect coverage for treatment done as part of special studies (Coverage with Evidence Development/CED, Medicare approved studies).  These changes only apply to members involved in the special studies.  The recent NCD changes are as follows:

Expanded coverage for donor stem cell transplant (allogenic hematopoietic stem cell transplant) for sickle cell disease, certain diseases of the blood cells (myelofibrosis, multiple myeloma), other rare diseases. In a donor stem cell transplant, a doctor takes part of a healthy donor's stem cell or bone marrow. This is then specially prepared and given to a patient through a tube in a vein (intravenous infusion). The patient also receives high dose chemotherapy (such as certain cancer drugs) and/or radiation treatments before getting this transplant through the vein.

This NCD expands coverage for donor HSCT items and services. These services will only be covered by Medicare if they are provided in a Medicare-approved clinical study under Coverage with Evidence Development (CED.). When bone marrow or peripheral blood stem cell transplantation is covered, all required steps are included in coverage.  If you think you qualify, speak with your physician.

This summarizes CMS transmittal R191NCD.

This affects services given on or after February 8, 2016
Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD's) that affect coverage for treatment done as part of special studies (Coverage with Evidence Development/CED, Medicare approved studies).  These changes only apply to members involved in the special studies.  The recent NCD changes are as follows:

  • Coverage will be approved for a special heart procedure (Left Atrial Appendage Closure, LAAC, if the device planned for use has FDA approval; and
  • You have a specific type of irregular heart beat (Non-Valvular Atrial Fibrillation, NVAF; and
  • You meet all the other specified conditions of the Medicare approved study.

These services will only be covered by Medicare if they are provided in a Medicare-approved clinical study under Coverage with Evidence Development (CED). If you think you qualify, speak with your physician.

This summarizes CMS transmittal R192NCD.

This affects services given on or after October 9, 2014
Cologuard is a test that is performed on a stool sample to check for colon cancer. You no longer need authorization from your health plan before you have this test done.

This summarizes CMS transmittal R183NCD.

This affects services given on or after August 30, 2016
Centers for Medicare and Medicaid Services (CMS) recently released a notice in response to public questions around gender reassignment surgeries. This notice restates that there are no national CMS coverage guidelines for this service. Coverage decisions for this type of surgery are made by your local Plan, according to your benefits and your Plan's medical necessity guidelines. If you have any questions about your coverage for this type of surgery, please contact Member Services at number on your Member ID.

This summarizes CMS transmittal R194NCD.

This affects services given on or after December 7, 2017.
Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD's) that affect coverage for treatment done as part of special studies (Coverage with Evidence Development/CED, Medicare approved studies). These changes only apply to members involved in the special studies. The recent NCD changes are as follows:

  • You are having surgery on your lower spine where the surgeon uses a very small incision and surgery is guided with imaging (x-ray) assistance (often referred to as “Percutaneous Image-guided Lumbar Decompression”/PILD).
  • You have a condition where the open spaces of your spine are narrowed and this puts pressure on your spinal cord or nerves (“Lumbar Spinal Stenosis”) and you have not had relief with non-surgical treatments.
  • You meet all the other specified conditions of the Medicare approved study.

These services will only be covered by Medicare if they are provided in a Medicare-approved clinical study under Coverage with Evidence Development (CED). If you think you qualify, speak with your physician.

This summarizes CMS transmittal R196NCD.

This affects services given on or after January 18, 2017
Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD's) that affect coverage for treatment done as part of special studies (Coverage with Evidence Development/CED, Medicare approved studies). These changes only apply to members involved in the special studies. The recent NCD changes are as follows:

  • Medicare will cover placement of a "leadless pacemaker" if you are enrolled in a special approved clinical study. A leadless pacemaker is placed without the need for a device pocket and insertion of a pacing lead which are parts of traditional pacing systems. You should speak with your doctor if you think you qualify to be a participant in an approved clinical study to receive this device."

This summarizes CMS transmittal R201NCD.

This is effective for services on or after May 25, 2017.

The Centers for Medicare and Medicaid Services (CMS) issued an NCD to cover SET for beneficiaries with intermittent claudication (IC) for the treatment of symptomatic PAD.

SET involves the use of intermittent walking exercise, which alternates periods of walking to moderate-to-maximum claudication, with rest. SET has been recommended as the initial treatment for patients suffering from IC, the most common symptom experienced by people with PAD.

The SET program must:

  • Consist of sessions lasting 30-60 minutes, comprising a therapeutic exercise-training program for PAD in patients with claudication
  • Be conducted in a hospital outpatient setting, or a physician’s office
  • Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD
  • Be under the direct supervision of a physician (as defined in Section 1861(r)(1)) of the Social Security Act (the Act), physician assistant, or nurse practitioner/clinical nurse specialist (as identified in Section 1861(aa)(5) of the Act)) who must be trained in both basic and advanced life support techniques.

This summarizes CMS transmittal R207NCD.