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Frequently Asked Questions About the Aetna Open Access® Plan*

* Members in our California HMO plan - Code 2X - must still obtain a referral from their PCP to see network specialists.
  1. What is the Aetna Open Access HMO Plan?
  2. What are the advantages of the Aetna Open Access HMO Plan?
  3. Can I go to any physician?
  4. Can I go to out-of-network providers?
  5. Do I have to select a primary care physician (PCP) under this plan?
  6. If I choose a PCP, can I choose a different doctor for my spouse and children?
  7. How can I find more information about providers in the Aetna Open Access HMO plan?
  8. What dental benefits are available in the Aetna Open Access HMO Plan?
  9. Do you offer a separate/supplemental Dental plan?
  10. What vision benefits are available in the Aetna Open Access HMO Plan?
  11. What are covered services or eligible expenses?
  12. What is a copayment?
  13. How does the copayment work?
  14. What do I do when I have an emergency? Do I call my doctor first?
  15. What online resources are available to help me use my benefits?
  16. How do I enroll in Aetna Open Access HMO?
  17. When will I get my ID card, and what do I use in the meantime?
  18. When does coverage become effective?
  19. I am being transferred to a new city that is also in Aetna's FEHBP approved service area. How do I enroll with you?
  20. How do I cover dependents that do not live with me?
  21. Will I be required to file any claim forms?
  22. I live in California, may I go to a specialist without a referral under the Open Access HMO Plan?
  23. Is the Aetna Open Access HMO available in any new sites this year?
  24. How is coverage handled overseas?



1. What is the Aetna Open Access® HMO Plan?

Members in the Aetna Open Access HMO plan have the freedom to visit any in-network provider (PCP or specialist) for covered services without a referral. You can find Aetna network providers by using our DocFind® online directory. We recommend that members select a primary care physician, but it is not required. If you receive services from a PCP that you have not selected, you will pay the specialist copay. Members pay a copayment for covered services. The copayment amounts for specific services vary and are listed in the Federal Plan brochure.

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2. What are the advantages of the Aetna Open Access HMO Plan?

The Aetna Open Access Plan provides a full range of medical, dental and vision benefits, access to an extensive network of over 470,000 providers, and the freedom to see Aetna network specialists without a referral.

Plan features include:
  • No referrals
  • Low cost
  • No deductible
  • No requirement to choose a primary care physician (PCP)
  • Basic dental included or you may select our Dental PPO network option at no extra charge
  • Expanded out-of-area dependent coverage
  • Vision Program including an eyewear reimbursement every 24 months
  • Emergency coverage
  • Online tools to help you manage your health


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3. Can I go to any physician?

No. You may visit any PCP or specialist in the Aetna network. You can find Aetna network providers by using our DocFind® online directory. DocFind® is updated three times per week.

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4. Can I go to out-of-network providers?

Out-of-network services and supplies are not covered under this Plan. However, eligible expenses for emergency care and urgent care services are covered. See section 5(d) Emergency Services/Accidents in the Federal Plan brochure.

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5. Do I have to select a primary care physician (PCP) under this plan?

No. While you do not have to select a PCP, we encourage you to establish a relationship with one as it can help you better manage your health. Your PCP can provide routine care, treat you for illnesses and injuries, or recommend that you see participating providers or specialists, if required. The higher specialist copayment will apply if you do not select a PCP and see that PCP for services.

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6. If I choose a PCP can I choose a different doctor for my spouse and children?

Yes, you may choose a different PCP for each member of your family. You may also request to change your PCP at any time.

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7. How can I find more information about providers in the Aetna Open Access HMO plan?

Use our DocFind® online directory. You can access information about our extensive network of over 470,000 providers as well as individual physicians' board certification status, medical school attended, the year he or she graduated, languages spoken, etc.

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8. What dental benefits are available in the Aetna Open Access HMO Plan?

You have two different dental options, Basic Dental or Dental PPO, from which to choose. New members are automatically enrolled in the Basic Dental option. With the Basic Dental, simply select a participating primary care dentist (PCD) and call Member Services at 1-800-537-9384 to register your selection. You may then contact the dentist to make an appointment. You pay a $5 office visit copayment for cleanings, amalgam fillings and X-rays. Other services are available from your selected PCD at a reduced fee. See your Federal Plan brochure for details.

If you would like to switch to our Dental PPO network option, you must call or submit your online request on or before the 15th of the month, your coverage in the Dental PPO option will be effective on the first of the following month (i.e., call on 1/8 and your coverage is effective on 2/1, but if you call on 1/17, your coverage will not be effective until 3/1). The Dental PPO network option gives you access to over 94,000 provider locations.

With the Dental PPO network option, each member pays a $20 annual deductible after which cleanings, amalgam fillings and X-rays are covered at 100% when using participating providers. Other services are available from participating providers at a reduced fee. With the Dental PPO network option you may also choose to go out of network. You are subject to the $20 annual deductible per member and cleanings, amalgam fillings and X-rays are covered at 50% of our negotiated fee. There are no benefits for additional services provided by an out-of-network provider.

You can find network providers by using our DocFind® online directory.

The advantages of switching to the Dental PPO network option are that you will have access to more licensed dentists and you will also have a limited out-of-network benefit. See Federal Plan brochure for details.

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9. Do you offer a separate Dental plan?

Yes. Aetna now offers a new Dental plan under the Federal Employees Dental and Vision Insurance Program (FEDVIP). Some key features are:
  • No deductibles
  • Visit any licensed dentist, in or out of network
  • No referrals
  • Coverage for major dental services, orthodontics and more
Visit the Dental section of our website for more information.

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10. What vision benefits are available in the Aetna Open Access HMO plan?

Routine eye exams are covered under the medical plan. See your Federal Plan brochure for details. Members are also eligible for an eyewear reimbursement every 24 months and discounts on frames, lenses, LASIK procedure, etc., through the Aetna VisionSM Discounts program.

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11. What are covered services or eligible expenses?

Covered services or eligible expenses are the benefits provided under the Plan, as described in the Federal Plan brochure.

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12. What is a copayment?

A copayment is the fixed dollar amount or percentage you must pay to a health care professional, facility or pharmacy when you receive covered services.

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13. How does the copayment work?

You pay a copayment at the time of service. The copayment will vary, depending on where the services are delivered and by whom (e.g., selected PCP, specialist, inpatient hospital stay, emergency room, outpatient hospital and pharmacy). Please see the Federal Plan brochure for copayment amounts.

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14. What do I do when I have an emergency? Do I call my doctor first?

Emergency Care Guidelines

If you need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the world. An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the person's health, or with respect to a pregnant woman, the health of the woman and her unborn child.

Call the local emergency hotline (ex. 911) or go to the nearest emergency facility. If you are admitted to an inpatient facility, you or a family member or friend on your behalf should notify Aetna as soon as possible.

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15. What online resources are available to help me use my benefits?

When you enroll in the Aetna Open Access HMO Plan, you have access to valuable online resources.

Aetna Navigator™ Member Website - Your personalized, self-service website packed with health and benefits information. When you register, you can order ID cards, check eligibility or claim status, e-mail customer service and much more. Here are just a few of the highlights:
  • Estimate the Cost of Care - compare the cost of brand-name drugs versus their generic equivalents.
  • Hospital Comparison Tool – see how hospitals in your area rank by factors important to you.
  • Aetna InteliHealth® and Healthwise® Knowledgebase websites – Health information sources to help you make better decisions about your health care and treatment options.
  • Personal Health Record - captures important health information in one place, helping you stay healthy with personalized alerts and reminders and allowing you to print and share your health history with your doctors.

    DocFind® - Aetna's online directory that lists participating physicians, hospitals and other health care providers. DocFind also includes important provider credentials like education, board certification and languages spoken.

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    16. How do I enroll in Aetna Open Access HMO?

    Enrollment procedures vary by agency. Detailed instructions and information on the Federal Employees Health Benefits Program enrollment process is available at Enroll Now. You will need to know the enrollment code for the Aetna Open Access Plan. Please refer to the rate calculator for the plans available in your area and the federal enrollment codes.

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    17. When will I get my ID card, and what do I use in the meantime?

    If you do not receive your ID card by your effective date, you may use a copy of your SF2809 Form or electronic enrollment (e.g. Employee Express, PostalEase, etc.) confirmation. If you are enrolled in our system, you may register on Aetna Navigator™ and print an ID card using the "Instant Eligibility" feature. After you register, simply click on your name under "Who Is Covered" and then select "Temporary Identification." You may use this printable version of your personal ID card if you need medical or dental care.

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    18. When does coverage become effective?

    Coverage and 2008 benefit changes for current members and annuitants begins on January 1, 2008. Coverage for new Aetna members (joining during Open Season) becomes effective on the first day of the first pay period in January 2008.

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    19. I am being transferred to a new city that is also in Aetna's FEHBP approved service area. How do I enroll with you?

    You will need to work with your personnel office to complete a new enrollment form. Please refer to the rate calculator for the plans available in your area and the federal enrollment codes.

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    20. How do I cover dependents that do not live with me?

    Eligible out-of-area dependents, such as children who are away at college, can be covered. To find out whether we have an Aetna HMO or Open Access HMO network in their area, go to our DocFind® online directory. If we do not have an Aetna HMO or Open Access HMO network in their area they would be covered for emergencies and urgent care, but would need to return home for routine care.

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    21. Will I be required to file any claim forms?

    Members usually should not need to file claim forms except in some out-of-network emergency care situations.

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    22. I live in California, may I go to a specialist without a referral under the Open Access HMO Plan?

    No, California members are covered under Aetna's HMO Plan and must continue to get referrals from their PCP in order to see network specialists.

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    23. Is the Aetna Open Access HMO Plan available in any new sites this year?

    Yes. We have expanded some existing service areas to include:
    Delaware (entire state)
    El Paso, TX
    Corpus Christi, TX

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    24. How is coverage handled overseas?

    You must live or work in our service area to enroll in our plans. See our rate calculator to find plans available in your area. Once enrolled in the plan, medical services received overseas would be covered for emergency or urgently needed care only.

    This material is for informational purposes only. See your federal brochure for a complete description of benefits, exclusions, limitations and conditions of coverage.
 

Open Access Features

  • PPO dental network option at no extra cost
  • No referrals
  • No claim forms
  • Nationwide access to the Aetna Open Access and HMO network of doctors.
  • Online provider directory
  • Aetna Navigator™ website features personal benefits information






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