09_28_301_1_VA Dental DMO (1/13)

09.28.301.1-VA (1/13)

Understanding your plan of

benefits

Aetna* dental benefits plans cover a variety of dental

services. But they do not cover everything. Your “plan

documents” list all the details for the plan you chose. Such

as, what’s covered, what’s not covered and the specific

amounts you will pay for services.

Plan document names vary. They may include a Schedule

of Benefits, Certificate of Coverage, Group Agreement,

Group Insurance Certificate, Group Insurance Policy and/or

any riders and updates that come with them.

If you can’t find your plan documents, call Member

Services to ask for a copy. Use the toll-free number on your

Aetna Dental ID card. You can also get a copy of the

Certificate of Coverage by contacting your employer

directly.

Warning: If you or your family members are covered

by more than one health care plan, you may not be

able to collect benefits from both plans. Each plan

may require you to follow its rules or use specific

doctors and hospitals, and it may be impossible to

comply with both plans at the same time. Before you

enroll in this plan, read all of the rules very carefully

and compare them with the rules of any other plan

that covers you or your family.

This managed care plan may not cover all of your health

care expenses. Read your contract carefully to determine

which health care services are covered. To contact the plan,

members may call the number on their ID card; all others,

call 1-877-238-6200.

Getting help

Member Services can help with your questions. To contact

Member Services, call the toll-free number on your Aetna

Dental ID card. You can also send Member Services an

e-mail. Just go to your secure member website at

www.aetna.com. Click on “Contact Us” after you log

on.

Member Services can help you:

■

Understand how your plan works or what you will pay

■

Get information about how to file a claim

■

Get a referral

■

Find care outside your area

■

File a complaint or appeal

■

Get copies of your plan documents

■

Find specific dental health information

■

And more

Hawaii

Insurance Division Telephone Number:

You may contact the Hawaii Insurance Division and the

Office of Consumer Complaints at: 1-808-586-2790.

Maryland

For quality of care issues and life and health care insurance

complaints, you may contact:

Aetna Dental Grievance and Appeals Unit

P.O. Box 14080

Lexington, KY 40512-4080

Toll-free phone: 1-877-238-6200

Maryland Insurance Administration of Life and Health

Insurance Complaints

200 Saint Paul Place, Suite 2700

Baltimore, MD 21202

Toll-free phone 1-800-492-6116

Local phone: 410-468-2244

Fax: 410-468-2243

www.aetna.com

Important information about your

dental benefits - Virginia

For the Dental Maintenance Organization (DMO)

*†

and Aetna Advantage Plus

™

Dental

plans.

*Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. Dental benefits and

dental insurance plans are underwritten by Aetna Dental Inc., Aetna Health Inc. Aetna and/or Aetna Life Insurance Company. Each insurer has sole

financial responsibility for its own products.

† In Illinois, DMO plans provide limited out-of-network benefits. In order to receive maximum benefits, members must select and have care coordinated

by a participating primary care dentist. Illinois DMO is not an HMO.

For help resolving a billing or payment dispute with the

dental plan or your dental care provider you may contact:

Aetna Dental Grievance and Appeals Unit

P.O. Box 14080

Lexington, KY 40512-4080

Telephone: 1-877-238-6200

Health Education and Advocacy Unit

Consumer Protection Division

Office of the Attorney General

16th Floor 200 Saint Paul Place

Baltimore, MD 21202

Telephone: 410-528-1840

Fax: 410-576-7040

Nothing herein shall be construed to require the plan to

pay counsel fees or any other fees or costs incurred by a

member in pursuing a complaint or appeal.

Virginia

Important information about your insurance

If you need to contact someone about this insurance for

any reason, please contact your agent. If no agent was

involved in the sale of this insurance, or if you have

questions, you may contact the insurance company issuing

this insurance at the following address and telephone

number:

Aetna Life Insurance Company

P.O. Box 14080

Lexington, KY 40512-4597

Toll-free phone: 1-877-238-6200

If you have been unable to contact or obtain satisfaction

from the company or the agent, you may contact the

Virginia State Corporation Commission’s Bureau of

Insurance at:

Life and Health Division Bureau of Insurance

P.O. Box 1157

Richmond, VA 23218

Local Phone: 804-371-9691

Fax: 804-371-9944

Office of the Managed Care Ombudsman

Bureau of Insurance

P.O. Box 1157

Richmond, VA 23218

Toll Free: 1-877-310-6560

Richmond Metropolitan Area: 804-371-9032

Fax: (804) 371-9944

e-mail: [email protected]

Or, you may contact the Virginia Department of Health,

Office of Licensure and Certification at:

Office of Licensure and Certification

Virginia Department of Health

9960 Mayland Drive, Suite 401

Henrico, VA 23233-1463

Fax#: 1-804-527-4503

Toll-free Phone: 1-800-955-1819

Richmond Metropolitan Area: 804-367-2106

Email: [email protected]

Written correspondence is preferable so that a record of

your inquiry is maintained. When contacting your agent,

company, the Bureau of Insurance or the Department of

Health, have your policy number available.

Aetna Life Insurance Company is regulated as a Managed

Care Health Insurance Plan (MCHIP) and as such, is subject

to regulation by both the Virginia State Corporation

Commission Bureau of Insurance and the Virginia

Department of Health.

Help for those who speak another

language and for the hearing impaired

Do you need help in another language? Member Services

representatives can connect you to a special line where you

can talk to someone in your own language. You can also

get interpretation assistance for registering a complaint or

appeal.

Language hotline: 1-877-238-6200 (140 languages are

available. You must ask for an interpreter.)

Ayuda para las personas que hablan otro idioma y

para personas con impedimentos auditivos

¿Necesita ayuda en otro idioma? Los representantes de

Servicios al Miembro le pueden conectar a una línea

especial donde puede hablar con alguien en su

propio idioma. También puede obtener asistencia de un

intérprete para presentar una queja o apelación.

Línea directa: 1-877-238-6200 (Tenemos 140 idiomas

disponibles. Debe pedir un intérprete.)

Search our network for dental care

providers

It’s important to know which dentists are in our network.

That’s because this dental plan only lets you visit dental

care providers if they are in our network.

Here’s how you can find out if your dentist is in our

network.

■

Log on to your secure member website at

www.aetna.com. Follow the path to find a doctor

and enter your dentist’s name in the search field.

www.aetna.com

■

Call us at the toll-free number on your Aetna Dental

ID card. If you don’t have your card, you can call us

at 1-877-238-6200.

Georgia

Members can call 1-877-238-6200 (toll free) to confirm

whether a dental provider is in the network and/or

accepting new patients. A summary of any agreement or

contract between Aetna and any dental care provider will

be made available upon request by calling the Member

Services telephone number on your ID card. The summary

will not include financial agreements as to actual rates,

reimbursements, charges or fees negotiated by Aetna and

the provider. The summary will include a category or type

of compensation paid by Aetna to each class of provider

under contract with Aetna.

Illinois

While every primary care dentist listed in the Dental

Directory contracts with Aetna to provide primary care

services, not every provider listed will be accepting new

patients. Although we have identified those providers who

were not accepting patients as known to us at the time

the Dental Directory was created, the status of the dental

practice may have changed. For the most current

information about the status change of any dental

practice, please contact either the selected dentist or

Member Services at the number on your ID card. You can

get more information about the network, participating

providers or our grievance procedures through the

DocFind

directory at www.aetna.com or by calling

1-877-238-6200.

Kentucky

Any dental care provider who meets our enrollment criteria

and who is willing to meet the terms and conditions for

participation has a right to become a participating provider

in our network.

Customary Waiting Times

Emergency/Immediately Urgent Care – within 24 hours

Routine Care – Within 5 weeks

Routine Hygiene Visit – Within 8 weeks

Michigan

Contact the Michigan Department of Consumer and

Industry Services at 517-373-0220 to verify participating

providers’ licenses or to access information on formal

complaints and disciplinary actions filed or taken against

participating providers.

Transition of Care When a Provider Leaves the Network

Our contracts are designed to provide transition of care for

covered persons should the treating dental care provider

contract terminate.

1. Participating dental care providers are contractually

obligated for continued treatment of certain members

after termination for any reason as outlined below:

“Provider shall remain obligated at company’s sole

discretion to provide covered services to: (a) any

member receiving active treatment from provider at the

time of termination until the course of treatment is

completed to company’s satisfaction or the orderly

transition of such member’s care to another provider by

the applicable affiliate of company; and (b) any

member, upon request of such member or the

applicable payor, until the anniversary date of such

member’s respective plan or for one (1) calendar year,

whichever is less. The terms of this agreement shall

apply to such services.”

2. In cases of provider termination, in order to allow for

the transition of members with minimal disruption to

participating providers, Aetna may permit a member

who has met certain requirements to continue an

“Active Course of Treatment” for covered benefits with

a non-participating provider for a transitional period of

time without penalty subject to any out-of-pocket

expenses outlined in the member’s plan design.

Costs and rules for using your

plan

What you pay

You will share in the cost of your dental care. These are

called “out-of-pocket” costs. Your plan documents show

the amounts that apply to your specific plan. Those costs

may include:

■

Copay – A fixed amount (for example, $15) you pay for

a covered health care service. You usually pay this when

you receive the service. The amount can vary by the

type of service. For example, the copay for your primary

dentist may be different than a specialist’s office visit.

■

Coinsurance – Your share of the costs for a covered

service. Coinsurance is calculated as a percent (for

example, 20%) of the allowed amount for the service.

■

Deductible – Some plans include a deductible. This is

the amount you owe for dental care services before

your dental plan begins to pay.

Your costs when you go outside the network

Aetna DMO is a network-only plan**. That means, the

plan covers dental care services only when provided by a

doctor who participates in the Aetna network. If you

receive services from an out-of-network dentist, you will

have to pay all of the costs for the services.

When you have no choice (for example: a dental

emergency while on vacation), we will pay the bill as if you

got care in network. You pay your plan’s copayments,

coinsurance and deductibles as you normally do. Under

federal health care reform (Affordable Care Act), the

government will allow some plans an exception to this

rule. Contact us if your dentist asks you to pay more. We

will help you determine if you need to pay that bill.

How we pay your dentist and how we calculate your

copay

This does not apply to “fixed copayments” that are for a

specified dollar amount.

Primary Care Services – A copayment applies to covered

primary care services rendered by your PCD. Subject to any

applicable state laws, your copayment is a percent of the

PCD’s usual fee for that service. We review those fees to

check that it is reasonable. The “usual fee” means the fee

that the PCD charges to his/her patients in general. You

can ask your PCD for a copy of the usual fee schedule.

This usual fee schedule may be changed from time to

time. It is used only for the purpose of calculating a

copayment and is not the basis for compensation to the

PCD. We compensate PCDs based on separate negotiated

agreements that may be less than or unrelated to the

PCD’s usual and customary charges. (These agreements

may vary among PCDs and may include per member per

month payments; chair hour rates; discounted fee-for-

service arrangements and/or other payment mechanisms).

Specialty Services – A copayment also applies to covered

specialty services. Your copayment is a percent of the

participating specialist dentist’s fee for that service. The

“fee” may be a fee negotiated with the participating

specialist dentist and approved by the plan. In that case,

your copayment will be based on the actual, negotiated

fee.

However, if we compensate the specialist dentist on

another basis, the “fee” will be the participating specialist

dentist’s usual fee. We review that fee to check that it is

reasonable. The “usual fee” means the fee that the

specialist charges to his/her patients in general and may be

changed from time to time. You can ask your specialist

dentist for a copy of the usual fee schedule. The usual fee

is used only for the purpose of calculating your copayment

and is not the basis for compensation to the participating

specialist dentist. We compensate participating specialist

dentists based on separate, negotiated agreements that

may be less than or unrelated to the dentist’s usual and

customary charges. These agreements may vary among

participating specialist dentists.

Choose a primary care dentist (PCD)

You must pick a primary care dentist, or “PCD,” who can

get to know your dental care needs and help you better

manage your dental care. You can designate any primary

care dentist who participates in the Aetna DMO network

and who is available to accept you or your family

members. If you do not pick a PCD, your benefits may be

limited or we may select a PCD for you.

A PCD is the dentist you go to for checkups, cleanings and

when you need dental care. If it’s an emergency, you don’t

have to call your PCD first. This one dentist can coordinate

all your care. Your PCD will refer you to a specialist when

needed.

Tell us who you chose to be your PCD

You may choose a different PCD from the Aetna DMO

network for each member of your family. Enter the name

of the PCD you have chosen on your enrollment form. Or

call Member Services after you enroll to tell us your

selection. The name of your PCD will appear on your

Aetna Dental ID card. You may change your selected PCD

at any time. If you change your PCD, you will receive a

new ID card.

Referrals: Your PCD will refer you to a

specialty dentist when needed

If you need specialty dental care, your PCD will give you a

referral to a specialist who participates in the Aetna

network. A “referral” is a written request for you to see

another dentist. Some dentists can send the referral

electronically to your specialist. There’s no paper involved!

Talk to your dentist to understand why you need to see a

specialist. Remember these points about referrals:

■

Always get the referral before you receive the care.

■

You do not need a referral for emergency care.

■

If you do not get a referral when required, you may

have to pay the bill yourself.

** State laws vary with regard to out-of-network benefits. In Illinois, DMO plans provide limited out-of-network benefits. However, to receive maximum

benefits, members must select and have care coordinated by a participating primary care dentist. In Ilinois, the DMO plan is not an HMO. In California,

for some services, your dentist may refer you to out-of-network care. See your plan documents for details.

www.aetna.com

■

Your specialist might recommend treatment or tests

that were not on the original referral. In that case, you

may need to get another referral from your PCP for

those services.

■

Referrals are valid for one year as long as you are still a

member of the plan. Your first visit must be within 90

days of the referral issue date.

■

You can get a special referral to go outside the network

if a network specialist is not available.

Emergency and urgent care

In the event of an emergency, call 911 or go to the nearest

emergency room. If a delay would not risk your health, call

your dentist or PCD.

You are covered for emergency treatment outside

your service area. Examples of an emergency include

severe pain, bleeding or infection. Pay the charges to the

dentist and submit a claim to the plan for reimbursement.

If the dentist was more than a specified distance away

from your PCD, then you will receive emergency benefits

coverage up to a maximum of $100*.

Knowing what is covered

You can avoid receiving an unexpected bill with a simple

call to Member Services. You can find out if a service is a

covered benefit — before you receive care — just by

calling the toll-free number on your Aetna Dental ID card.

We have developed a dental clinical review program to

help us determine what dental services are covered under

the dental plan and the extent of that coverage. Some

services may be subject to a review after you received the

care. Only dental consultants who are licensed dentists

make clinical determinations. We will notify you and your

dentist if we deny coverage for any reason. The reason is

stated on our notification. For more information about

Clinical Reviews or any other topic, please call the number

on your Aetna Dental ID card.

What to do if you disagree

with us

Complaints, appeals and external review

Please tell us if you are not satisfied with a response you

received from us or with how we do business.

Call Member Services to file a verbal complaint or to

ask for the appropriate address to mail a written

complaint. The phone number is on your Aetna Dental ID

card. You can also e-mail Member Services through the

secure member website.

If you’re not satisfied after talking to a Member Services

representative, you can ask that your issue be sent to the

appropriate department.

If you don’t agree with a denied claim, you can file

an appeal. To file an appeal, write to us at the applicable

address, as follows:

■

Northeast Territory – includes Mid-Atlantic and North

Eastern states (CT, DE, DC, IL, IN, KY, ME, MD, MA, MI,

NH, NJ, NY, OH, PA, RI, VA, VT, WV, WI)

Aetna Dental Grievance and Appeals Unit

P.O. Box 14080

Lexington, KY 40512-4080

■

South Territory – (AL, AR, FL, GA, LA, MS, NC, OK, SC,

TN, TX)

Aetna Dental Grievance and Appeals Unit

P.O. Box 14597

Lexington, KY 40512-4597

■

West Territory – (AK, AZ, CA, CO, HI, IA, ID, KS, MN,

MO, MT, ND, NE, NV, NM, OR, SD, UT, WA, WY)

Aetna Dental Grievance and Appeals Unit

P.O. Box 10462

Van Nuys, CA 91410

The complaint and appeal processes can be different

depending on your plan and where you live. Some states

have laws that include their own processes. So it’s best to

check your plan documents or talk to someone in Member

Services to see how it works for you.

Link to your state insurance department website

Visit the National Association of Insurance Commissioners

(NAIC) at www.naic.org.

Kentucky appeals process

1. As a member of Aetna, you have the right to file an

appeal about service(s) you have received from your

dental care provider or Aetna, when you are not

satisfied with the outcome of the initial determination

and the request is regarding a change in the decision

for:

■

Certification of health care services

■

Claim payment

■

Plan interpretation

■

Benefit determination

■

Eligibility

* Refer to your plan documents. Subject to state requirements. Out-of-area emergency dental care may be reviewed by our dental consultants to verify

appropriateness of treatment.

2. You or your authorized representative may file an

appeal within 180 days of an initial determination. You

may contact Member Services at the number listed on

your identification card.

3. A Customer Resolution Consultant will acknowledge

the appeal within five (5) business days of receipt. A

Customer Resolution Consultant may call you or your

dental care provider for dental records and/or other

pertinent information.

4. Our goal is to complete the appeal process within 30

days of receipt of your appeal. An appeal file is

reviewed by an individual who was neither involved in

any prior coverage determinations related to the appeal

nor a subordinate of the person who rendered a prior

coverage determination. A dentist or other appropriate

clinical peer will review clinical appeals. A letter of

resolution will be sent to you upon completion of the

appeal. It is important to note that it is a covered

member’s right to submit new clinical information at

any time during the appeal of an adverse determination

or coverage denial to an insurer or provider.

5. If the appeal is for a decision not to certify urgent or

ongoing services, it should be requested as an

expedited appeal. An example of an expedited appeal is

a case where a delay in making a decision might

seriously jeopardize the life or health of the member or

jeopardizes the member’s ability to regain maximum

function. An expedited appeal will be resolved within

72 hours. If you do not agree with the final

determination on review, you have the right to bring a

civil action under Section 502(a) of ERISA, if applicable.

6. If you are dissatisfied with the outcome of a clinical

appeal and the amount of the treatment or service

would cost the covered individual at least $100.00 if

they had no insurance, you may request a review by an

external review organization (ERO). The request must be

made within 60 days of the final internal review. A

request form will be included in your final determination

letter. It can also be obtained by calling Member

Services. A decision will be rendered by the ERO within

21 calendar days of your request. An expedited process

is available to address clinical urgency. If you disagree

with the decision regarding your right to an external

review, you may file a complaint with the Kentucky

Department of Insurance.

7. As a member, you may, at any time, contact your local

state agency that regulates health care service plans for

complaint and appeal issues, which Aetna has not

resolved or has not resolved to your satisfaction.

Requests may be submitted to:

Kentucky Department of Insurance

P.O. Box 517

Frankfort, KY 40602-0517

8. You and your plan may have other voluntary alternative

dispute resolution options, such as mediation. One way

to find out what may be available is to contact your

plan administrator, your local U.S. Department of Labor

Office and your state insurance regulatory agency.

We protect your privacy

We consider your personal information to be private. Our

policies help us protect your privacy. By “personal

information,” we mean information about your physical

condition, the health care you receive and what your

health care costs. Personal information does not include

what is available to the public. For example, anyone can

find out what your health plan covers or how it works. It

also does not include summarized reports that do not

identify you.

Below is a summary of our privacy policy. For a copy of our

actual policy, go to www.aetna.com. You’ll find the

“Privacy Notices” link at the bottom of the page. You can

also write to:

Aetna Legal Support Services Department

151 Farmington Avenue, W121

Hartford, CT 06156

Summary of the Aetna privacy policy

We have policies and procedures in place to protect your

personal information from unlawful use and disclosure. We

may share your information to help with your care or

treatment and administer our health plans and programs.

We use your information internally, share it with our

affiliates, and we may disclose it to:

■

Your doctors, dentists, pharmacies, hospitals and other

caregivers

■

Those who pay for your health care services. That can

include health care provider organizations and

employers who fund their own health plans or who

share the costs.

■

Other insurers

■

Third-party administrators

■

Vendors

■

Consultants

■

Government authorities and their respective agents

These parties must also keep your information private.

Doctors in the Aetna network must allow you to see your

medical records within a reasonable time after you ask for

them.

Some of the ways we use your personal information

include:

■

Paying claims

■

Making decisions about what to cover

■

Coordinating payments with other insurers

■

Preventive health, early detection, and disease and case

management

We consider these activities key for the operation of our

health plans. We usually will not ask if it’s okay to share

your information unless the law requires us to. We will ask

your permission to disclose personal information if it is for

marketing purposes. Our policies include how to handle

requests for your information if you are unable to give

consent.

Member Rights

We publish a list of rights and responsibilities on our

website. Visit www.aetna.com/individuals-families-

healthinsurance/member-guidelines/member-

rights.html to view the list. You can also call Member

Services at the number on your ID card to ask for a printed

copy.

Hawaii

Informed Consent:

Members have the right to be fully informed when making

any decision about any treatment, benefit or

nontreatment. Your dental provider will:

■

Discuss all treatment options, including the option of no

treatment at all

■

Ensure that persons with disabilities have an effective

means of communication with the provider and other

members of the managed care plan

■

Discuss all risks, benefits and consequences to

treatment and nontreatment

Kansas

Kansas law permits you to have the following information

upon request:

■

A complete description of the dental care services, items

and other benefits to which the insured is entitled in the

particular dental plan that is covering or being offered

to such person

■

A description of any limitations, exceptions or exclusions

to coverage in the dental benefit plan, including prior

authorization policies or other provisions that restrict

access to covered services or items by the insured

■

A listing of the plan’s participating dental care providers,

their business addresses and telephone numbers, their

availability, and any limitation on an insured’s choice of

provider

■

Notification in advance of any changes in the dental

benefit plan that either reduces the coverage or benefits

or increases the cost, to such person

■

A description of the grievance and appeal procedures

available under the dental benefit plan and an insured’s

rights regarding termination, disenrollment, nonrenewal

or cancellation of coverage

Washington State

The following materials are available: any documents

referred to in the enrollment agreement; any applicable

preauthorization procedures; dentist compensation

arrangements and descriptions of and justification for

provider compensation programs; circumstances under

which the plan may retrospectively deny coverage

previously authorized.

Dental benefits and dental insurance plans are underwritten by Aetna Dental Inc., Aetna Health Inc. and/or Aetna Life Insurance Company. Each insurer

has sole financial responsibility for its own products. Providers are independent contractors and are not agents of Aetna. Provider participation may

change without notice. Aetna does not provide care or guarantee access to dental services. Information subject to change.

Notes