Important info about your Aetna Better Health® of Virginia plan
Get to know your rights and responsibilities, quality and case management programs, accessing benefits and services like pharmacy, privacy info and more.
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Where to find important info about your plan
Your rights and responsibilities
How we make decisions about your health care (utilization management)
Where to find important info
Your Aetna Better Health member handbook covers everything you need to know about your health plan. You can find info on:
- What your plan covers, and what it does not
- How to get your medicine and use your pharmacy benefits
- Copays and other costs you may need to pay
- What’s covered outside the Aetna Better Health network
- How to get language help at no cost
- How to ask for auxiliary aids and services at no cost
- How to submit a claim
- How to get info about providers in the Aetna Better Health network
- How to get primary care services
- How to get specialty care. This includes:
- Behavioral health care
- Hospital services
- Care for specific conditions
- How to get a referral
- How to get care after normal office hours
- How and when to use emergency room care
- How to get care outside of your service area
- How to file a complaint or grievance
- How to appeal a decision that affects your coverage, benefits or relationship with your plan
- How we decide which new services or tools we cover
- How we make decisions about your care (called utilization management)
- Your member rights and responsibilities
- Notice of privacy practices
We update the handbook every year. If we make major changes, we will send you a letter at least 30 days before they start.
You can view your handbook online at AetnaBetterHealth.com/virginia/member-materials-forms.html.
Prefer a hard copy? Call us at 1-800-279-1878 (TTY: 711) to have one mailed to you. Let us know if you need it in another language, a larger font or other formats.
Get the most out of your benefits
Your rights and responsibilities
As an Aetna Better Health member, you have certain rights and responsibilities.
Your rights include:
- A right to get info about:
- The organization and its services
- The organization’s practitioners and providers
- Your member rights and responsibilities
- A right to be treated with respect and dignity
- A right to privacy
- A right to work with your providers to make decisions about your health care
- A right to talk openly about treatment options, regardless of cost or benefit coverage
- A right to voice complaints or submit appeals about the organization or the care it provides
- A right to give feedback on the organization’s member rights and responsibilities policy
Your responsibilities include:
- A responsibility to give info that the organization and its providers need to provide you with care
- A responsibility to follow plans for care that you have agreed to with your providers
- A responsibility to understand your health problems and join in developing treatment goals
Go to AetnaBetterHealth.com/virginia/medicaid-rights-responsibilities.html for a complete list of your rights and responsibilities.
Your pharmacy benefits
Learn more about your pharmacy benefits at AetnaBetterHealth.com/virginia/pharmacy-prescription-drug-benefits.html. You can find info such as:
- Preferred drug list (PDL) or formulary
- Medications that require prior authorization and coverage criteria
- A list and explanation of medications that have limits or quotas
- Copayment and coinsurance requirements and the medications or classes to which they apply
- Steps for getting clinical or PDL prior authorization, generic substitution or preferred brand interchange
- Info on pharmaceutical management procedures
- Criteria used to add new medicines to the formulary
- How to ask for a coverage exception
How we make decisions about your health care
Our utilization management (UM) program ensures you get the right care in the right setting when you need it. UM staff can help you and your providers make decisions about your health care.
When we make decisions, it’s important for you to remember the following:
- We make UM decisions by looking at your benefits and clinical guidelines for the most appropriate care and service. We consider:
- Your needs
- Evidenced-based practice
- Availability of care
- You also must have active coverage.
- We don’t reward providers or other people for denying coverage or care.
- Our employees do not get any incentives to reduce the services you get.
If you have questions about UM, call Member Services. They can also help if you need language translation or support.
Get extra support for your health care needs
Every Aetna Better Health member is on their own health care journey. We can help guide you in managing and improving your health. Our population health management programs can help with things like:
- Managing a health condition
- Pregnancy care
- When to use urgent care
- What to do after a hospital stay
- Staying healthy and preventing health problems
You can learn more about our programs at AetnaBetterHealth.com/virginia/population-health-programs.html or in your member handbook.
For most programs, we will automatically enroll you if you are eligible. You can choose to join or leave a program at any time by calling Member Services.
You can also get a referral to a management program. Referrals can come from:
- Your provider
- A medical management program
- Hospital discharge planner
- A caregiver
- Yourself
Call us at 1-800-279-1878 (TTY: 711) or go to our website for a member referral into case management.
Care you can trust
Our network providers follow proven care guidelines. These guidelines:
- Are based on strong medical evidence or agreement among experts in the field
- Take members’ needs into account
- Are created with input from the providers we work with
- Are checked and updated at least every two years
You or your provider can call us for a copy of these guidelines. Find out more at AetnaBetterHealth.com/virginia/providers/clinical-guidelines-policy-bulletins.html.
Quality matters
You deserve the best care. And we work with your provider to make sure that happens.
Our Quality Improvement (QI) program helps us make our services better. We share info about our QI program with members every year. You can find this info at AetnaBetterHealth.com/virginia/quality-improvement-program.html.
We care about your privacy
We protect your personal health information (PHI). That includes your:
- Race
- Ethnicity
- Language
- Sexual orientation
- Social needs info
- Disability status
We only share your info when needed and as allowed by law.
You have rights over your health data. That includes how it’s used and who can access it. Go to AetnaBetterHealth.com/health-optimization-disclaimer.html to learn more about your privacy rights and how we safeguard your data.
Language assistance
Aetna follows applicable Federal civil rights laws. Aetna does not discriminate on the basis of race, color, national origin, age, disability, or sex.
Don't speak English or need auxiliary aids and services? Aetna provides interpreter services at no cost, including sign language interpreters. Call the number on the back of your ID card for help. You can also ask for written info in another language or format, including:
- Large print
- Audio
- Accessible electronic formats
Go to AetnaBetterHealth.com/virginia/notice-of-non-discrimination.html for more info.
ENGLISH: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call the number on the back of your ID card or 1-800-385-4104 (TTY: 711).
SPANISH: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al número que aparece en el reverso de su tarjeta de identificación o al 1-800-385-4104 (TTY: 711).
KOREAN: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 귀하의 ID 카드 뒷면에 있는 번호로나 1-800-385-4104 (TTY: 711) 번으로 연락해 주십시오.
VIETNAMESE: CHÚ Ý: nếu bạn nói tiếng việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Hãy gọi số có ở mặt sau thẻ id của bạn hoặc 1-800-385-4104 (TTY: 711).
CHINESE: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電您的 ID 卡背面的電話號碼或 1-800-385-4104 (TTY: 711)。
ARABIC:ملحوظة: إذا كنت تتحدث باللغة العربية، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل على الرقم الموجود خلف بطاقتك الشخصية أو على الرقم 4104-385-800-1 (للصم والبكم: 711)
TAGALOG: PAUNAWA: Kung nagsasalita ka ng wikang Tagalog, mayroon kang magagamit na mga libreng serbisyo para sa tulong sa wika. Tumawag sa numero na nasa likod ng iyong ID card o sa 1-800-385-4104 (TTY: 711).
PERSIAN:
اگر به زبان فارسی صحبت می کنید، به صورت رایگان می توانید به خدمات کمک زبانی دسترسی داشته باشید. با شماره درج شده در پشت کارت شناسایی یا با شماره 4104-385-800-1 (TTY:711) تماس بگیرید.
AMHARIC: ማሳሰቢያ:- አማርኛ የሚናገሩ ከሆነ ያለ ምንም ክፍያ የቋንቋ ድጋፍ አገልግሎቶችን ማግኘት ይችላሉ። በእርስዎ አይዲ ካርድ ጀርባ ወዳለው ስልክ ቁጥር ወይም በስልክ ቁጥር 1-800-385-4104 (TTY: 711) ይደውሉ።
URDU:
توجہ دیں: اگر آپ اردو زبان بولتے ہیں، تو زبان سے متعلق مدد کی خدمات آپ کے لیے مفت دستیاب ہیں۔ اپنے شناختی کارڈ پر رابطہ کریں۔ (TTY: 711) 1-800-385-4104 کے پیچھے موجود نمبر پر یا
FRENCH: ATTENTION: si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le numéro indiqué au verso de votre carte d’identité ou le 1-800-385-4104 (ATS: 711).
RUSSIAN: ВНИМАНИЕ: если вы говорите на русском языке, вам могут предоставить бесплатные услуги перевода. Позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки, или по номеру 1-800-385-4104 (TTY: 711).
HINDI: ध्यान दें: यदि आप हिंदी भाषा बोलते हैं तो आपके लिए भाषा सहायता सेवाएं नि:शुल्क उपलब्ध हैं। अपने आईडी कार्ड के पृष्ठ भाग में दिए गए नम्बर अथवा 1-1800-385-4104 (TTY: 711) पर कॉल करें।
GERMAN: ACHTUNG: Wenn Sie deutschen sprechen, können Sie unseren kostenlosen Sprachservice nutzen. Rufen Sie die Nummer auf der Rückseite Ihrer ID-Karte oder 1-800-385-4104 (TTY: 711) an.
BENGALI: লক্ষ্য করুনঃ যদি আপনি বাংলায় কথা বলেন, তাহলে নিঃখরচায় ভাষা সহায়তা পরিষেবা উপলব্ধ আছে। আপনার পরিচয়পত্রের উল্টোদিকে থাকা নম্বরে অথবা 1-800-385-4104 (TTY: 711) নম্বরে ফোন করুন।
KRU: TÛ DƐ NÂ JÍÉ BÒ: Ɛ yemâ wlu bɛ̀ɛ̀ ^n a po Klào Win, néé â-a win kwa cɛtiyɔ+ ne-là, I bɛlé-ò bi
má- ò mû bó k ò putu bɔ̀. Da nɔbâ né ɛ́ nea-ó n-à jíé jipolê katéh jɛ́ ná kpóh,mɔ̀ó 1-800-385-4104 (TTY:711).
IGBO (IBO): NRỤBAMA: Ọ bụrụ na ị na asụ Igbo, ọrụ enyemaka asụsụ, n’efu, dịịrị gị. Kpọọ nọmba dị n’azụ nke kaadị ID gị ma ọ bụ 1-800-385-4104 (TTY: 711).
YORUBA: ákiyési: Ti o ba sọ Yorùbá, áwọn olùránlowo ipésé édé ti wa ni le fùn o loféé, pe nonbá ti o wá léyin káádi idánimo ré tábi 1-800-385-4104 (TTY: 711).
