Aetna Better Health of West Virginia... Member Services 1‑‑4‑2922 • TTY 711 1Welcome to Aetna Better Health® of West Virginia Your decision to join Aetna Better

WV-17-06-02

Aetna Better Health® of West Virginia

2017–2018 Member HandbookLearn about your health care benefits

www.aetnabetterhealth.com/westvirginia

Member Services 1-888-348-2922 (TTY: 711)

Behavioral Health 1-888-348-2922

24-Hour Informed Health Line 1-855-200-5975

Vision 1-800-877-7195

Dental 1-888-983-4693 (TTY: 1-800-508-6975)

Non-Emergent Transportation 1-844-549-8353

DHHR Change Center 1-877-716-1212

Prescription Drugs 1-888-483-0797

Enrollment Broker 1-800-449-8466

Mailing address Aetna Better Health of West Virginia 500 Virginia Street East, Suite 400 Charleston, WV 25301

Website www.aetnabetterhealth.com/westvirginia

Personal information

Helpful Information

_____________________________________________________My PCP (Primary care provider)

_____________________________________________________

My PCP’s phone number

_____________________________________________________ My member ID number

www.aetnabetterhealth.com/westvirginia Member Services 1‑888‑348‑2922 • TTY: 711 1

Welcome to Aetna Better Health® of West Virginia

Your decision to join Aetna Better Health was a significant one for you and your covered family members. On behalf of all of those associated with our plan, we welcome you. We have built a strong network of area practitioners, hospitals and other health care providers to offer a wide range of services for your medical needs.

As an Aetna Better Health member, it is important that you understand the way your plan works. This Member Handbook contains the information you need to know about your Aetna Better Health benefits.

Please take some time to read these materials to learn more about your Aetna Better Health coverage. We are available to answer any questions you may have about your coverage and services. You can reach us at 1‑888‑348‑2922, Monday through Friday, 8:30 a.m. to 5 p.m. (ET). If you are hearing or speech impaired, you can dial 711 and they can connect you to the number listed above.

We look forward to serving you and your family.

www.aetnabetterhealth.com/westvirginia Member Services 1‑888‑348‑2922 • TTY: 7112


Table of contentsTranslation services ......................................................................................................................................................... 7Confidentiality and request for your medical records ..................................................................................... 8

Discrimination ................................................................................................................................................................. 8Definitions ............................................................................................................................................................................ 9

Aetna Better Health Provider Directory/Aetna Better Health provider network ........................................ 9Complaint ......................................................................................................................................................................... 9Cosmetic services and surgery ................................................................................................................................... 9

SECTION 1 ..................................................................................................................................................................................12Important information about your Aetna Better Health coverage .........................................................12

Facts about Aetna Better Health .............................................................................................................................12Aetna Better Health Annual Community Report ...............................................................................................12Quality Management Program ................................................................................................................................13

SECTION 2 ..................................................................................................................................................................................14Your rights and responsibilities................................................................................................................................14

Your rights .......................................................................................................................................................................14Your responsibilities .....................................................................................................................................................15Notice of HMO Patient Bill of Rights ......................................................................................................................15

SECTION 3 ..................................................................................................................................................................................17Using your benefits ........................................................................................................................................................17

Getting help ...................................................................................................................................................................17Inquiries ...........................................................................................................................................................................1724‑Hour care .................................................................................................................................................................1824‑Hour Informed Health Line (formerly called our Nurse Helpline) .........................................................18After Hours Behavioral Health Crisis Line ............................................................................................................18How to use your Aetna Better Health of West Virginia services ....................................................................18Aetna Better Health member ID card and Medicaid card ...............................................................................19Primary Care Practitioner (PCP) ...............................................................................................................................20OB/GYN practitioner....................................................................................................................................................21Changing your PCP ......................................................................................................................................................21Patient Utilization Management and Safety (PUMS) program ......................................................................21Change in Aetna Better Health benefits or services .........................................................................................21Access and availability standards ............................................................................................................................21Continuing services from providers .......................................................................................................................22When you may have to pay for services ................................................................................................................22Providers not in the Aetna Better Health network ............................................................................................22Referrals ...........................................................................................................................................................................23Specialists and Behavioral Health practitioners .................................................................................................23Utilization Management ............................................................................................................................................23Utilization Management affirmative statement about incentives ..............................................................23Preauthorized care ‑ care that must be approved .............................................................................................23


“Carved‑Out” services ................................................................................................................................................24Non‑emergent transportation ................................................................................................................................25Prescription drugs ........................................................................................................................................................25Third Party Liability (TPL) ............................................................................................................................................25Care away from home .................................................................................................................................................25Reporting fraudulent activity ....................................................................................................................................25

SECTION 4 ..................................................................................................................................................................................26Covered services and limits........................................................................................................................................26

Care Management .......................................................................................................................................................26Disease Management .................................................................................................................................................27Behavioral Health care (mental health care/substance use disorder) ........................................................27Chiropractic services ...................................................................................................................................................27Court ordered services ................................................................................................................................................27Dental services (child) .................................................................................................................................................27Dental services (adult) .................................................................................................................................................28Oral surgery including dental accidents ...............................................................................................................28Durable Medical Equipment (DME) and medical supplies ..............................................................................28Early and Periodic Screening, Diagnosis and Treatment (EPSDT) .................................................................29Eye care and eye glasses ............................................................................................................................................31Family planning services and supplies ...................................................................................................................31High‑risk prenatal services ........................................................................................................................................32Home health care .........................................................................................................................................................32Inpatient hospital care ................................................................................................................................................32Maternity .........................................................................................................................................................................33Nurse midwife ...............................................................................................................................................................33Outpatient hospital care ............................................................................................................................................33Practitioner services .....................................................................................................................................................34Second medical opinion ............................................................................................................................................35Sexually transmitted disease treatment ...............................................................................................................35Therapy services ...........................................................................................................................................................35Urgent care .....................................................................................................................................................................35Vision services ................................................................................................................................................................35Well‑care services .........................................................................................................................................................35Women's health care services ..................................................................................................................................35Member co‑payments ................................................................................................................................................38Medical co‑payments table ......................................................................................................................................39Maximum Out of Pocket (OOP) ...............................................................................................................................39Out of Pocket maximum table .................................................................................................................................39

SECTION 5 ..................................................................................................................................................................................40Emergency services .......................................................................................................................................................40

What is an emergency? ..............................................................................................................................................40Payment for emergency services ............................................................................................................................41Post stabilization care ..................................................................................................................................................41


SECTION 6 ..................................................................................................................................................................................41General services not covered....................................................................................................................................41

SECTION 7 ..................................................................................................................................................................................42Complaints, Appeals and State Fair Hearings ...................................................................................................42

Complaints .....................................................................................................................................................................43Appeals ............................................................................................................................................................................43State Fair Hearings .......................................................................................................................................................45General notes ................................................................................................................................................................45Your benefits during the appeal or State Fair Hearing Process ......................................................................46

SECTION 8 ..................................................................................................................................................................................46Eligibility and enrollment............................................................................................................................................46

Eligibility ...........................................................................................................................................................................46Enrollment ......................................................................................................................................................................46Changes in enrollment ...............................................................................................................................................46Adding a newborn baby .............................................................................................................................................46Disenrollment ................................................................................................................................................................47Termination ....................................................................................................................................................................47

SECTION 9 ..................................................................................................................................................................................47Terms and conditions ....................................................................................................................................................47

Co‑payments .................................................................................................................................................................47If you get a bill or statement ......................................................................................................................................47Relationship to contracting parties ........................................................................................................................47Advance directives .......................................................................................................................................................48Changes ...........................................................................................................................................................................48Entire agreement ..........................................................................................................................................................48Notice of Insurance Information Practices (abbreviated) ...............................................................................48Coordination of benefits ............................................................................................................................................49Transfer of benefits and payments .........................................................................................................................49Treatment of Minors ....................................................................................................................................................49

Aetna Better Health of West Virginia service area (statewide) .................................................................50Value-add services .........................................................................................................................................................50



Translation servicesAetna Better Health of West Virginia Member ServicesToll‑free 1‑888‑348‑2922 TTY: 711

If you do not understand English, call Member Services at 1‑888‑348‑2922 for help. We will provide the information about your benefits to you in a language you can understand. We can also help you communicate with your practitioner.


Confidentiality and request for your medical recordsWe understand the importance of keeping your personal and health information secure and private. We are required by law to provide you with the Notice of Privacy Practices. This notice is included in your member packet and on our website. This notice informs you of your rights about the privacy of your personal information and how we may use and share your personal information. Changes to this notice will apply to the information that we already have about you as well as any information that we may receive or create in the future.

You may request a copy of this notice at any time by calling Member Services at 1‑888‑348‑2922 or by going to our website at www.aetnabetterhealth.com/westvirginia. Both Aetna Better Health of West Virginia and your practitioners make sure that all your member records are kept safe and private. We limit access to your personal information to those who need it. We maintain safeguards to protect it. For example, we protect access to our buildings and computer systems. Our Privacy Office also assures the training of our staff on our privacy and security policies.

To properly service your benefits, we may use and share your personal information for “treatment,” “payment” and “health care operations.” We may limit the amount of information that we share about you as required by law. For example, HIV/AIDS, substance abuse and genetic information may be further protected by law. Our privacy policies will always reflect the most protective laws that apply.

In your practitioner's office, your medical record will be labeled with your identification and stored in a safe location in the office where other people cannot see your information. If your medical information is on a computer, there is a special password needed to see that information.

Your medical record cannot be sent to anyone else without your written permission, unless required by law. When you ask your practitioner's office to transfer records, they will give you a release form to sign. It is your practitioner's responsibility to do this service for you. If you have a problem getting your records or having them sent to another practitioner, please contact Member Services at 1‑888‑348‑2922; TTY: 711. Member Services will assist you in obtaining records within 30 days of the receipt of the record request. We will assist you:• To provide quick transfer of records to other in or out‑of‑network practitioners for the medical management of

your health.• When you change Primary Care Practitioners, to assure that your medical records or copies of medical records

are made available to your new Primary Care Practitioner.

If you would like a copy of your medical or personal records that we maintain, you may send us a written request. You may also call Aetna Better Health Member Services at 1‑888‑348‑2922; TTY: 711 and ask for a form that you or your representative can fill out and send back to us. When we get your written request, we will send your requested records within 30 days unless we let you know in writing that it will take longer. At no time, should it take more than 60 days from the date of your written request for your records to be sent to you. You have a right to review your requested medical records and ask that they be amended or corrected.

DiscriminationYour benefits must comply with the 1964 Civil Rights Act. Discriminatory administration of benefits because of sex, race, color, religion, national origin, ancestry, age, political affiliation, or physical, developmental, or mental challenges is not allowed. If you have questions, complaints, or want to talk about whether you have a disability according to the Americans with Disabilities Act, you can contact the State ADA Coordinator at:

WV Department of AdministrationBuilding 1, Room E‑1191900 Kanawha Blvd. East,Charleston, WV 25305(304) 558‑4331


DefinitionsAdultA member who is age 21 or older.

Advance DirectiveA legal document through which a person may provide directions or express preferences concerning his/her medical care and/or to appoint someone to act on his/her behalf.

AgreementThe contract between Aetna Better Health of West Virginia and the West Virginia Department of Health and Human Resources (DHHR). This Handbook is a part of the agreement.

Aetna Better Health (we, our, us)The Medicaid program offered by us.

Aetna Better Health Practitioner (practitioner)/participating practitionerA doctor, psychologist, nurse practitioner or other duly licensed health professional, such as a nurse midwife that has directly or indirectly signed a contract with us to be part of the Aetna Better Health network. These practitioners are also called participating practitioners. The Provider Directory and the Aetna Better Health website will show these Aetna Better Health practitioners. Please be aware that the list changes.

Aetna Better Health Provider (provider)/participating providerA hospital, or other duly licensed institution that has directly or indirectly signed a contract with us to be part of the Aetna Better Health network. These providers are also called participating providers. The Provider Directory and the Aetna Better Health website will show these Aetna Better Health providers. Please be aware that the list changes.

Aetna Better Health Provider Directory/Aetna Better Health provider networkA list of providers and practitioners that have contracted with us to provide care to Aetna Better Health members. This list changes based on new providers joining our network and other practitioners moving or retiring. Our Aetna Better Health website, www.aetnabetterhealth.com/westvirginia, has a provider list that is updated nightly. You can also call Member Services at 1‑888‑348‑2922; TTY: 711 and request a hard copy of the Provider Directory.

AppealA request by member or their representative for review and reconsideration of a decision with respect to an action. This includes both coverage and non‑coverage determinations.

Bureau for Medical Services (BMS)The agency within DHHR which decides whether or not a person is eligible for Medicaid.

Child(ren)A member who is under age 21.

ComplaintAny written or verbal expression of dissatisfaction. For the purposes of this handbook, the terms complaint and grievance can be used interchangeably.

Contract yearJuly 1 through the following June 30.

Cosmetic services and surgeryServices and surgery that are mainly to improve your looks. Cosmetic services and surgery do not help your body work better or keep you from getting sick.

Covered services (covered care/care)The medical care, services or supplies which we will pay. This care is described in this Handbook.

Department of Health and Human Resources (DHHR)The West Virginia Department of Health and Human Resources.


Early and Periodic Screening, Diagnosis and Treatment (EPSDT)A program of preventive health care and well‑child checkups with age‑appropriate tests and shots.

EmergencyA sudden onset of a medical, behavioral health, or dental condition that shows itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson to result in: (i) serious jeopardy to the mental or physical health of the member; or (ii) danger of serious impairment of the member's bodily functions; or (iii) serious dysfunction of any of the member's bodily organs; or (iv) in the case of a pregnant woman, serious jeopardy to the health of the fetus. In the case of behavioral health services, emergency care means clinical, rehabilitative, or supportive behavioral health services provided for which a prudent layperson with an average knowledge of health and medicine, could reasonably expect to result in risk of danger to a person's self or others if not immediately treated. These include, but are not limited to, crisis stabilization treatment services.

Experimental/investigationalCare or a supply is experimental or investigational if it includes, but is not limited to, any of the following:• It is in the testing stage or in early field trials on animals or humans.• It is under clinical investigation by health professionals or is undergoing clinical trial by any governmental agency,

including but not limited to, the Department of Health and Human Services or the Food and Drug Administration (FDA). Any drug not approved for use by the FDA, any FDA approved drug prescribed for an off‑label use whose effectiveness is unproven based on clinical evidence reported in peer‑reviewed medical literature, or any drug that is classified as an Investigational New Drug (IND) by the FDA. As used herein, off‑label prescribing means prescribing prescription drugs for treatments other than those stated in the labeling approved by the FDA. Drugs for the treatment of a specific type of cancer that are not FDA approved will be covered when they are approved for one type of cancer for which the drug has been prescribed in any of the standard reference compendia. Similarly, drugs for the treatment of a specific indication that are not FDA approved will be covered so long as the drug has been approved by the FDA for at least one indication and the drug is recognized for treatment of the covered indication in one of the Standard Reference Compendia or in substantially accepted Peer‑Reviewed Medical Literature.

• It is a health product or service that is subject to Investigational Review Board (IRB) review or approval.• Any health product or service that is the subject of a clinical trial that meets criteria for Phase I, II or III as set forth

by FDA regulations, except as specifically covered by defined criteria.• It does not have required final federal regulatory approval for commercial distribution for the specific indications

and methods of use assessed or have not been approved by the Centers for Medicare and Medicaid Services for coverage by Medicaid.

• Any health product or service whose effectiveness is unproven based on clinical evidence reported in Peer‑Reviewed Medical Literature.

Family planning careFamily planning care helps you to plan your family size. It gives you information on birth control methods.

GrievanceAetna Better Health of West Virginia uses the term complaint to mean “any expression of dissatisfaction”. For the purposes of this handbook, the terms complaint and grievance can be used interchangeably.

HMOAetna Better Health of West Virginia, as an HMO (Health Maintenance Organization), is subject to regulation in West Virginia by the State Insurance Commission. For the purposes of this Handbook, an HMO is considered to be a Managed Care Entity (MCE) or a Managed Care Organization (MCO).

Medically necessary (medically needed/needed)The use of services or supplies rendered by a hospital, practitioner or other provider needed to find or treat a member's illness or injury. We must also feel that the care is: (1) consistent with the symptoms or diagnosis and treatment of the member's condition, disease, ailment or injury; (2) appropriate with regard to standards of good medical practice; (3) not solely for the convenience of the member, his/her practitioner, hospital, or other health


care provider; and (4) the most appropriate supply or level of service that can be safely given to the member. For members in the hospital, it also means the member's medical symptoms or condition cannot be diagnosed or treated safely out of a hospital.

MemberAny person who gets services from Department of Health and Human Resources (DHHR) and who has Aetna Better Health coverage.

Member Handbook (Handbook)This book, as well as any amendment or related document sent together with this book, that tells you about your coverage and your rights.

Member Services DepartmentOur Member Services staff can answer questions about your Aetna Better Health benefits. Our toll‑free number is 1‑888‑348‑2922 or TTY: 711. Member Services is available from 8:30 a.m. to 5 p.m., Monday through Friday; and you are also able to reach a call center representative 24 hours a day, 7 days a week.

Patient-Centered Medical HomeA health care setting that facilitates partnerships between individual patients and their personal physicians and, when appropriate, the patients' families and communities. A patient‑centered medical home integrates patients as active participants in their own health and well‑being.

Post‑stabilization careMedically needed care a member gets after an emergency condition has been stabilized.

Preauthorization/preauthorizedApproval by us that is needed so that we will pay for certain services to be done.

Primary Care Practitioner (PCP)The Aetna Better Health practitioner you pick to give you primary health care. This practitioner will arrange for most other care you need as well. All members must pick a PCP. PCPs specialize in the areas of general practice, family practice, internal medicine and pediatrics. For female members age 13 or older, the member can also pick an OB/GYN practitioner to give you primary health care and arrange for most other care you need. If you select an OB/GYN practitioner, he/she is considered a PCP.

Prudent laypersonA person who is without medical training and who draws on his or her practical experience when making a decision regarding whether emergency medical treatment is needed. A prudent layperson will be considered to have acted “reasonably” if other similarly situated laypersons would have believed, on the basis of observation of the medical symptoms at hand, that emergency medical treatment was needed.

Service areaThe geographic area where you can get care under the Aetna Better Health program.

Specialty care practitioner/specialistA practitioner who gives health care to members within his or her range of specialty. For the purposes of this Handbook, an OB/GYN is not always a specialty care practitioner since an OB/GYN may be a PCP.

Urgent careUrgent care is medically needed care for an unexpected illness or injury that you need sooner than a routine practitioner's visit.

WebsiteRefers to www.aetnabetterhealth.com/westvirginia.

You, yourRefers to a member.


Section 1Important information about your Aetna Better Health coverageIf you need to contact someone about your Aetna Better Health coverage for any reason, please contact us at:

Aetna Better Health of West VirginiaATTN: Member Services500 Virginia Street East, Suite 400Charleston, WV 253011‑888‑348‑2922; TTY: 711

Please make sure you read and understand the grievance procedure in this Handbook, and use it before taking any other action. Below are the addresses and telephone numbers for complaints/grievances and appeals.

Complaints/grievancesAetna Better Health of West VirginiaATTN: Member Services500 Virginia Street East, Suite 400Charleston, WV 253011‑888‑348‑2922; TTY: 711

AppealsAetna Better Health of West VirginiaATTN: Appeals Coordinator500 Virginia Street East, Suite 400Charleston, WV 253011‑888‑348‑2922; TTY: 711

If you are unable to contact or obtain help from us, you may contact the Department of Health and Human Resources (DHHR) Bureau for Medical Services or West Virginia Offices of The Insurance Commissioner at:

DHHR ‑ Bureau for Medical ServicesOffice of Medicaid Managed Care350 Capitol Street, Room 251Charleston, WV 25301‑3708

The Office of the Insurance CommissionerP.O. Box 50540Charleston, WV 25305‑0540

Writing to the Bureau for Medical Services or the Office of the Insurance Commission is better than calling so that a record of your inquiry is kept. If you are not satisfied with the decision of the Office of the Insurance Commissioner, you may appeal to Circuit Court. You must file your appeal within 30 days after the Insurance Commissioner's order has been mailed.

Facts about Aetna Better HealthAetna Better Health of West Virginia is a Managed Care Organization duly licensed in accordance with the laws of the state of West Virginia. We offer coverage for the Medicaid Mountain Health Trust and West Virginia Health Bridge programs.

We contract with practitioners, hospitals, and other medical providers to give care to our Aetna Better Health members. They make up Aetna Better Health's provider network and are called participating providers. You should use these providers whenever possible.

We do not pay extra money to providers for deciding if you do or do not need care. We only pay providers for the care you receive. If you have questions about how we pay providers, call us at 1‑888‑348‑2922 to ask for this information.

Aetna Better Health Annual Community ReportA copy of the Aetna Better Health Annual Community Report is available to you. If you would like a copy, call us at 1‑888‑348‑2922; TTY: 711.


Quality Management ProgramAetna Better Health has a Quality Management (QM) Program to make sure our services meet high standards of quality and safety. We want to make sure you have:• The right kind of care.• Easy access to quality medical, dental, and Behavioral Health care.• Help with any chronic conditions or illnesses.• Support when you need it most.• High satisfaction with your doctors and with us.

We work hard to improve the quality of your health care. Some of our quality programs are:• Surveying members and providers to measure satisfaction.• Calling members to remind them to get their care (like taking your child for a checkup).• Educating members by sending postcards or newsletters.• Reviewing the type, amount and quality of services given to members.• Working with members who have serious health issues through Care Management and Disease Management.• Giving members' information on the website about what health care costs.• Reminding providers and members about preventive health care.• Measuring standards like how long it takes for a member to get an appointment.• Monitoring phone calls to make sure your call is answered as quickly as possible and that you get correct

information.• Reviewing calls and complaints from members.• Reviewing all aspects of the health plan with health plan staff, providers, and members through committees.

This list is just some of our quality programs. We review and update our QM Program each year. Call us at 1‑888‑348‑2922 or visit our website at www.aetnabetterhealth.com/westvirginia to find out more about our quality programs. You can also ask for a written description of our QM Program.


Section 2Your rights and responsibilitiesAll members have certain rights and responsibilities. They are listed below.

Your rightsYou have the right to:• Get information about Aetna Better Health and the services we cover, the doctors who provide care, and the

member rights and responsibilities.• Get covered benefits or services regardless of gender, race, ethnicity, age, religion, national origin, sexual

orientation, physical or mental disability, type of illness or condition, ability to pay or ability to speak English.• Accessible services• Pick a doctor who works with our provider network.• Be treated with respect and dignity.• Privacy when you are at an office visit, getting treatment or talking to staff at the health plan.• Not have your medical records shown to others without your approval, unless allowed by law.• Find out what is in your medical records, or have an authorized representative find out what is in your medical

record, as allowed by law, and request a copy of your medical records.• Request, or have an authorized representative request, an amendment or correction to your medical record in

accordance with law.• Ask for a list of people who were given a copy of your medical records.• Be involved in deciding on the type of care you want or do not want.• Say no to treatment or services and be told what may happen if you refuse the treatment. You can continue to

get Medicaid and medical care even if you refuse treatment.• Refuse care from a doctor you were referred to and ask for a referral to a different doctor.• Have your doctor tell you how he or she plans to treat you. The doctor should tell you if other treatments can be

used and the risks for each one no matter how much they cost or if Aetna Better Health will pay for it.• Know the cost to you if you choose to get a service that Aetna Better Health does not cover.• Receive information about how to submit a complaint, grievance, appeal, or request for a hearing about Aetna

Better Health or the care received.• Tell us about your grievances about Aetna Better Health and the care you get from your doctors.• Appeal a decision.• Use the methods described in this Handbook to share questions and concerns about your health care or about

Aetna Better Health.• Tell us about ways to improve our policies and procedures, including the member rights and responsibilities.• Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation,

as specified in other Federal regulations on the use of restraints and seclusion.• Receive treatment and information that is sensitive to your cultural or ethnic background.• Get interpretation services if you do not speak English or have a hearing impairment to help you get the medical

services you need.• Ask for materials to be presented in a manner or language that you understand at no cost to you.• Receive information about advance directives or a living will, which tell how to have medical decisions made for

you if you are not able to make them for yourself.• Know how Aetna Better Health pays providers, controls costs and uses services.• Get emergency health care services without the approval of your primary care provider (PCP) or Aetna Better

Health when you have a true medical, behavioral health or dental emergency.• Be told in writing by Aetna Better Health when any of your health care services requested by your PCP are

reduced, suspended, terminated or denied. You must follow the instructions in your notification letter.• Receive information about practitioner incentive plans upon request.


Your responsibilitiesYou have the responsibility to:• Read this Member Handbook. It tells you about our services and how to file a grievance or appeal.• Follow Aetna Better Health rules.• Know the name of your PCP and Care Manager.• Show your identification (ID) card to each doctor before getting health services.• Protect your member ID card. Do not lose or share it with others.• Use the emergency room (ER) for true emergencies only.• Make and keep appointments with doctors. If you need to cancel an appointment, it must be done at least

twenty‑four (24) hours before your scheduled visit.• Treat the doctors, staff and people providing services to you with respect.• Give all information about your health to Aetna Better Health and your doctor. This includes immunization

records for members under age twenty‑one (21).• Tell your doctor if you do not understand what they tell you about your health. You and your doctor can make

plans together about your care.• Follow what you and your doctor agree to do. Make follow‑up appointments. Take medicines and follow your

doctor's care instructions.• Schedule wellness check‑ups. Members under twenty‑one (21) years of age need to follow the Early Periodic

Screening Diagnosis and Treatment (EPSDT) schedule.• Get care as soon as you know you are pregnant. Keep all prenatal appointments.• Tell Aetna Better Health and the BMS when your address changes. Call the DHHR Change Report Center

at 1‑877‑716‑1212. Then call Aetna Better Health of West Virginia Member Services toll‑free at 1‑888‑348‑2922. Tell them about family changes that might affect eligibility or enrollment. Some examples are change in family size, employment, and moving out of the State of West Virginia.

• Tell Aetna Better Health if you have other health insurance, including Medicare.• Give your doctor a copy of your living will and/or advance directive.

Notice of HMO Patient Bill of RightsAs required by the West Virginia Department of Insurance, Aetna Better Health of West Virginia, Inc. is providing the following annual notice to HMO enrollees.

You have the right to:• A description of your rights and responsibilities, plan benefits, benefit limitations, premiums and individual

cost‑sharing requirements.• A description of the health plan's grievance and hearing procedures and the right to pursue grievance and

hearing procedures without reprisal from the Managed Care plan.• A description of the method in which you can obtain a list of the plan's provider network, including the names

and credentials of all participating practitioners, and the method by which you may choose practitioners within the plan.

• Choose an available participating Primary Care Practitioner (PCP), and with proper referrals, the right to a participating specialist.

• Privacy and confidentiality with regard to your personal information.• Full disclosure from your health care practitioner of any information relating to your medical condition or

treatment plan and the ability to examine and offer corrections to your own medical records.• Be informed of plan policies and any charges for which you will be responsible.• Ask for the procedures Aetna Better Health uses to control the use of services and costs.• A description of the procedures for obtaining out‑of‑area services.• A description of the method by which you can obtain access to a summary of the plan's accreditation report.• Have medical advice or options communicated to you without any limitations or restrictions being placed upon

the practitioner or PCP by the health plan.• Have all coverage denials reviewed by appropriate medical professionals consistent with the health plan's review

procedure.


• Have coverage denials involving medical necessity or experimental treatment reviewed, after exhaustion of the health plan's internal grievance procedure, by appropriate medical professionals who are knowledgeable about the recommended or requested health care service, as part of an external review.

• Emergency services without prior authorization if prudent layperson acting reasonably would have believed that an emergency medical condition existed, and the right to a description of procedures to obtain emergency services.

• Direct access, annually, to your OB/GYN for the purpose of a well woman examination without a referral from your PCP, and no woman shall be required to obtain a referral from her PCP as a condition to coverage of prenatal or obstetrical care.

• Reconstruction of the breast following mastectomy and reconstructive or cosmetic surgery required as a result of an injury caused by the act of a person convicted of a crime involving family violence. This applies to a member whose plan provides coverage for surgical services in an inpatient or outpatient setting.

• The following when performed for cancer screening or diagnostic purposes: (1) a baseline mammogram for women age thirty‑five to thirty‑nine, inclusive; (2) a mammogram for women age 40 to 49, inclusive, at least every two years; (3) a mammogram every year for women age 50 and over; (4) a pap smear at least annually for women age 18 and over. This applies to a woman whose plan provides coverage for laboratory or X‑ray services.

• Colorectal cancer examinations and laboratory tests for colorectal cancer for a non‑symptomatic member over 50 years of age and symptomatic member under 50 years of age.

• Rehabilitation services.• Child immunization (shots) services, which shall not be subject to payment of any deductible, per‑visit charge

and/or copayment.• Direct access to an optometrist or ophthalmologist of your choice from the panel without referral from your PCP

for an annual diabetic retinal examination for diabetics whose health benefits policy includes eye care benefits. When the diabetic retinal examination reveals the beginning stages of an abnormal condition, access to future examinations shall be subject to prior authorization from a PCP.


Section 3Using your benefits

Getting helpWe are here to help you. Our Member Services team will help you get answers to questions about your health care, ID cards, and practitioners. You can call Member Services at 1‑888‑348‑2922; TTY: 711 when you have a problem or question.

InquiriesInquiries are oral or written communications that we receive from members or member representatives.

Inquiries can be about:• The rules allowing you or a family member to get and keep Aetna Better Health coverage.• The health care services available to you as an Aetna Better Health member.• The rules we have for you to get your health care services.• The Handbook and other information we send to you.• Giving us your new address if you move.• PCP assignment.• Translation services.

If you want to make an inquiry, call Member Services at 1‑888‑348‑2922; TTY: 711. We will make every effort to respond to your inquiry on that phone call. If we cannot completely respond to your inquiry on the phone, we will call or write you back within 30 working days of the inquiry. If you want to write to us, send the information to:

Aetna Better Health of West VirginiaAttn: Member Services500 Virginia Street East, Suite 400Charleston, WV 25301

We will respond to your written inquiry in writing within 30 working days of the date we received the inquiry.

If your primary language is not English or you have a hearing impairment, you have the right by law to interpreter services. This is an Aetna Better Health covered service. This service is free and you don't need to rely on a family member or friend to interpret for you. Just tell your practitioner that you need a translator or sign language interpreter and he or she will call us. We will make arrangements for signing or language interpreter services when your practitioner discusses treatment, medical history, or health education with you. You may also call Member Services at 1‑888‑348‑2922; TTY: 711 to ask for a translator or sign language interpreter.

If you need to contact us about your benefits and your primary language is not English, we will contact our language line service, which will translate for you.

For our members with hearing disabilities who have access to TTY telephones, if you need to contact us, you may call 711.

If you are visually impaired, call Member Services at 1‑888‑348‑2922; TTY: 711 to ask about getting this Handbook in a larger print or a recorded or audio taped version.

If you have questions about when you can start getting care under Aetna Better Health or how long you can receive care from us, call Member Services at 1‑888‑348‑2922; TTY: 711.

You may also find answers to many of your questions on our website www.aetnabetterhealth.com/westvirginia. Select “For Members” to learn more about benefits and services for you and your family. You can also check the services that require preauthorization, read the latest issue of our member newsletter or ask us a question using the online form when you register on our secure member web portal. To register, go to our website and select “Login” from the homepage.


MyActiveHealth is an easy way to take charge of your health. So you can feel better ‑ for good. And as a member of Aetna Better Health of West Virginia, you'll get MyActiveHealth at no cost to you. To access the site, just sign into your secure member portal at www.aetnabetterhealth.com/westvirginia. Once signed in, you can:• Complete health surveys and keep track of health records.• Get help for health goals like quitting smoking and weight management.• Sign up for digital health coaching programs.• Find information on healthy lifestyle programs.• View health and wellness videos and podcasts.• Access the member portal and MyActiveHealth from any device ‑ computer, tablet or smartphone.

24-Hour careYou will choose a Primary Care Practitioner (also called a PCP) who can take care of your health needs, 24 hours a day, every day. You can call your PCP for care anytime, day or night. When your PCP is out, he or she will have someone to take his or her place. Your PCP or your PCP's on‑call practitioner will be able to help you at all hours of the day and night, even on weekends and holidays. For routine and urgent care, call your PCP.

To see your PCP, just call your practitioner's office and make plans for a visit. If you need health care and your PCP's office is closed, you should still call his or her office and tell them you are an Aetna Better Health member. Your PCP or someone from his or her office will call you back.

24-Hour Informed Health Line (formerly called our Nurse Helpline)We encourage you to work with your PCP for your health care needs. However, if you have a medical question and you are not sure what to do, call our 24‑Hour Informed Health Line. Our Informed Health Line can help you answer specific health questions. You can also get advice on what to do when you need health care, such as calling your PCP, making an appointment, or going immediately to the Emergency Room. The toll‑free number for the Informed Health Line is 1‑855‑200‑5975. You can also find the Informed Health Line number on the back of your Aetna Better Health ID card.

After Hours Behavioral Health Crisis LineIf you believe your health is in immediate danger due to a behavioral health concern, please go to your nearest Emergency Room. If you are not sure you are in a crisis situation and it is outside of working hours (after 5:00 p.m. (ET), Monday‑Friday, weekends and holidays), you may call our Behavioral Health Crisis Line at 1‑888‑348‑2922, Option 2. You will talk with a counselor who will assist you with your concerns.

How to use your Aetna Better Health of West Virginia servicesHere are a few easy steps to follow so that we will pay for your health care:• Call your PCP and set up a time for a checkup. As soon as you get your ID card, even if you are not sick, you should set up a time to see your PCP for a checkup.

This way, your PCP can get to know you better and help stop future health problems before they happen, or at least find them sooner.

Your PCP will look for any problems you might have because of your age, weight and habits. Your PCP will also help you find ways to be healthy.

Children should also see their PCP for checkups, shots and screenings as soon as possible. For checkups, shots and screenings, try to call your PCP two or three weeks ahead to ask for an appointment.

SSI members are encouraged to schedule an appointment with the PCP or specialist who manages your care within 45 days of initial enrollment.

When you or someone in your family is sick and needs health care, call your PCP and set up a time for a visit. You can see your practitioner at his or her office.

If you need help scheduling your appointment call Member Services at 1‑888‑348‑2922; TTY: 711.


• Keep your appointments. Please do not miss your practitioner visits. Your practitioner can take better care of you when you are there for each visit. Give your practitioner at least 24‑hours notice if you cannot keep your appointment.

• Your PCP will decide who else you need to see. If your PCP says you need other tests or you need to see another practitioner, he or she will send you to the practitioner best suited for your needs. Your PCP will help you make plans with other Aetna Better Health providers when you need special care. You do not need a PCP referral for Behavioral Health services. You can pick a practitioner in the Aetna Better Health of West Virginia network by going to www.aetnabetterhealth.com/westvirginia and clicking “Find a Provider” from the top navigation menu.

• You can call your PCP after hours. If you need health care and your PCP's office is closed, you should still call his or her office if it is not an emergency. Leave a message to tell them you are an Aetna Better Health member. In your message, give the reason for your call and leave your name and phone number where someone can reach you. Your PCP or a practitioner on call for your PCP will call you back. He or she will tell you where to get care.

Aetna Better Health member ID card and Medicaid cardWhen you join Aetna Better Health, each family member receives his or her own Aetna Better Health ID card. Make sure to keep your ID card in a safe place since this is your only Aetna Better Health ID card. Always carry your Aetna Better Health ID card and your West Virginia Medicaid card. Always show both cards when you see a health care provider. These cards will let the practitioner know you are an Aetna Better Health member and which program covers you (Mountain Health Trust or WV Health Bridge). Your Aetna Better Health member ID card shows the first date you can use it to get care from us under Aetna Better Health.

Front of Aetna Better Health ID Card(Mountain Health Trust)

Front of Aetna Better Health ID Card(WV Health Bridge)

Back of ID Card

Back of ID Card


Information on your Aetna Better Health ID card includes the following:• Your name• Your Aetna Better Health/Medicaid ID number• Your date of birth• Your Primary Care Practitioner's name• Your Primary Care Practitioner's office phone number• The day your Aetna Better Health coverage starts• Benefit program logo for Mountain Health Trust or WV Health Bridge• Important phone numbers

If you need an Aetna Better Health ID card, call Member Services at 1‑888‑348‑2922; TTY: 711. If a card is lost or stolen, please call us immediately.

Primary Care Practitioner (PCP)Aetna Better Health members choose their PCP from our Aetna Better Health Provider Directory. Your Aetna Better Health Member ID card will list your PCP's name. We will tell you if your PCP stops being an Aetna Better Health practitioner. We will help you pick a new practitioner. If you do not pick a new PCP, we will pick one for you.

Each time you need to go to your PCP, you should call to set up your visit. Please show up for your visits. If you cannot get to your PCP for your visit, call your PCP's office to cancel, giving at least 24‑hours notice.

If your PCP is not there when you need care, you should ask to see one of the other practitioners in the group. Also, there may be a practitioner on call for your PCP that you could see.

If you have a disabling condition or chronic illness, you may ask to have an Aetna Better Health specialist as your PCP. Also, Aetna Better Health specialists may act as PCPs in giving care for special needs children. Either you or your practitioner should contact Member Services at 1‑888‑348‑2922; TTY: 711 to make this request.

To find a participating practitioner or specialist, go to www.aetnabetterhealth.com/westvirginia. Select “Find a Provider” in the top navigation area, and then “Enter Provider Search.” You can search by zip code or county and state. You can even narrow results down to a particular specialty if needed. If you need help finding a provider or specialist near you, call Member Services at 1‑888‑348‑2922; TTY: 711.

If you have Diabetes• Visit your practitioner at least twice a year.• Take all medication as prescribed by your practitioner.• If you need to see a diabetes specialist you will want to see an Endocrinologist.• Have a yearly diabetic eye exam (they will need to dilate your eyes).• Have your HbA1c checked at least twice a year.• Have your cholesterol checked once a year.• Have your kidneys checked once a year with a urine test for microscopic protein.

If you have Asthma or COPD• Visit your practitioner at least twice a year.• Take all medication as prescribed by your practitioner, even if you feel well.• If you need a lung specialist you will want to see a Pulmonologist and/or Allergist.• Follow your Asthma Action Plan. Know what to do if your symptoms get worse.

If you have High Cholesterol• Have your cholesterol checked at least once a year.• Take all medication as prescribed by your practitioner.• If you are overweight, ask your practitioner for weight loss guidelines.• Get at least 30 minutes of exercise on most days.


If you have Heart Disease• Visit your practitioner at least twice a year.• If you need a heart specialist you will want to see a Cardiologist.• If you smoke, stop (ask your practitioner about getting help with this).• If you are overweight, even a small amount of weight loss will help.• Have your cholesterol checked at least once a year.• Have your blood pressure checked (take your medicine, as ordered, if the practitioner has prescribed some for

you).

OB/GYN practitionerIf you are a female age 13 or over you may get female‑related services directly from a participating obstetrical/gynecological practitioner (also called an OB/GYN) without asking your PCP. You will need to see an Aetna Better Health OB/GYN. You can pick your practitioner from our Aetna Better Health Provider Directory.

Changing your PCPYou can change your PCP on our secure member web portal at www.aetnabetterhealth.com/westvirginia. Select “Log in.” Or you can call Member Services at 1‑888‑348‑2922; TTY: 711. You need to do this before you visit your new practitioner. Your change will happen immediately and an updated ID card will be issued within 5 business days.

Patient Utilization Management and Safety (PUMS) programWe have a Patient Utilization Management and Safety (PUMS) program. We can restrict members to one provider if a pattern of abuse is demonstrated.

If you have been enrolled in the PUMS program through another Managed Care Organization or through the Department of Health and Human Resources, you may be automatically enrolled in Aetna Better Health's PUMS program. If you have been restricted to one provider or practitioner and you disenroll from Aetna Better Health and you re‑enroll within six months, you may be placed back in the PUMS program.

You have the right to request an appeal (including the right to request a State Fair Hearing) of the decision to restrict you to one provider.

Change in Aetna Better Health benefits or servicesIf there is a change in the Aetna Better Health benefits or services that are available to you, we will let you know within 30 days of, or no later than, the effective date of the change. We will let you know by telling you in writing or as an update to this Handbook.

Access and availability standardsThe following are the access and availability standards for different situations for our Aetna Better Health members:

Member Visits You should see a practitioner…Regular/routine primary care (nonurgent) appointments

Within 21 calendar days

Urgent complaint appointment Within 48 hoursEmergency appointment ImmediatelyFirst prenatal visit Within 14 days of pregnancy confirmation24‑hour availability 24 hours a day; 7 days a weekSpecialty Care – new patient/initial visit Within 90 calendar daysSpecialty Care – follow‑up visit Within 30 calendar days


Member Visits You should see a practitioner…Initial Behavioral Health visit Within 10 business daysUrgent Behavioral Health visit Within 48 hoursCare for non‑life threatening Behavioral Health emergency

Within 6 hours

Follow‑up care with a Behavioral Health practitioner Within 60 calendar days

This chart shows how long it should take to travel to a practitioner's appointment.

The amount of time it takes to get to … Should be no longer than …PCPs and specialists you see often 30 minutesBasic hospital services 45 minutesTertiary services 60 minutes

Continuing services from providersIf your Aetna Better Health practitioner leaves our provider network, you may continue to receive covered services from this practitioner in the following cases:

You may receive covered services from your PCP for up to 90 calendar days after the date your PCP has given to, or received from us, notice that his or her participation status in Aetna Better Health is ending. This can only take place if your PCP remains in the Aetna Better Health service area and is open to see patients.

You may receive covered services from practitioners other than your PCP for a period of at least 90 calendar days if you were in an active course of treatment with an Aetna Better Health practitioner before the practitioner's notice of termination from our provider network. You must make a request to continue receiving health care services from that practitioner.

You are able to receive care for extended periods under the following circumstances:• If you have entered your second trimester of pregnancy at the time your practitioner's participation is terminated

and your services from that practitioner are directly related to the delivery through postpartum care.• If you have a medical prognosis of life expectancy that is six (6) months or less, you may continue to receive

treatment from such practitioner for the remainder of your life for care directly related to the treatment of the terminal illness.

The continuity of care options described above are not available if your practitioner is terminated for cause or if you are no longer an Aetna Better Health member. We will pay the practitioner for covered services you receive as described above according to our agreement with the practitioner.

If your practitioner leaves our network, call us for help at 1‑888‑348‑2922; TTY: 711.

When you may have to pay for servicesYou may have to pay for care you get from a practitioner who is not part of the Aetna Better Health provider network. We can tell you if a practitioner is part of our provider network, just call 1‑888‑348‑2922; TTY: 711. Sometimes we will pay for your care even if you do not go to an Aetna Better Health provider:• For care in an emergency.• For urgent care outside Aetna Better Health's provider network, when approved by us.• When your PCP sends you and we preauthorize the care before your visit.• For family planning services.

Providers not in the Aetna Better Health networkYour practitioner may tell you that you need to see a practitioner or other health care provider who is not an Aetna Better Health provider. If so, he or she must send the health information we need to review the request.


You can go to a provider outside the Aetna Better Health network only if: (1) the care is needed; and (2) there are no Aetna Better Health providers who can give you the care needed. We have the right to say where the service can be given when no Aetna Better Health provider can give you the care needed. The care must be preauthorized before your visit. The practitioner that wants to give you the care should ask for this preauthorization.

If we have approved care outside our network, there is no cost to you. If you have questions, call Member Services at 1‑888‑348‑2922; TTY: 711.

ReferralsWe do not require you to get a referral from your PCP or OB/GYN before you see another in‑network provider. You still should call your PCP to let them know you are going to the other provider. This helps your PCP coordinate your care. Some services may need to be preauthorized.

Specialists and Behavioral Health practitionersSpecialists and Behavioral Health practitioners are practitioners who have special training to treat certain problems. Sometimes your PCP may want you to see a specialist or a Behavioral Health practitioner so that they can treat you more effectively. For a list of Aetna Better Health specialists and Behavioral Health practitioners, please call us at 1‑888‑348‑2922; TTY: 711 or visit www.aetnabetterhealth.com/westvirginia.

Utilization ManagementWe know that you want to feel sure that you are getting the right health care and services in the right place. This is called Utilization Management (UM). Our UM staff uses clinical review criteria, practice guidelines and written policies to make UM decisions. UM decisions are based on these reasons:• Services requested are medically needed (also called medically necessary)• Services requested are covered in the member's plan

Utilization Management affirmative statement about incentivesWe understand members want to feel confident they are receiving the health care and services that are best for them. We have policies our practitioners and providers follow to ensure you receive the right healthcare. We do not use incentives to encourage barriers to care and/or service, or to reward inappropriate restrictions of care. This is called an affirmative statement.

We want to let you know that:• Utilization Management decisions are based only on appropriateness of care and services and whether they are

covered.• We do not reward or pay our network of providers or employees to deny reviews.• No financial incentives are offered to encourage underutilization.

We want to make sure that each member receives the right healthcare. If you need help understanding this information, call us at 1‑888‑348‑2922; TTY: 711.

Preauthorized care - care that must be approvedWe must preauthorize some health care, drugs and supplies you get. We give preauthorization to Aetna Better Health providers when you need health care, drugs or supplies that are medically needed and are listed below. At a minimum, your practitioner needs to call us three (3) working days before the scheduled care. However, earlier notification greatly facilitates the review process. We may ask to see written notes showing that the care is medically needed before it is preauthorized. Our Preauthorization team is available from 8:30 a.m. ‑ 5 p.m. (ET). If you have questions, call Member Services at 1‑888‑348‑2922; TTY: 711.

You must get your first service on the date or within the dates listed on your preauthorization. If you cannot get the care on the date or within the dates listed on your preauthorization or you need more visits, you must call your practitioner. Your practitioner will call us to change the preauthorized dates. Preauthorizations are good for a specific amount of time. The preauthorization does not go past your last covered date.

Your preauthorization for care is for a specific problem or sometimes for a set number of visits. If you run out of visits and still need more, call your practitioner. Your practitioner must call us to add more visits.


You can speak to a person to ask questions about the pre‑approval/pre authorization process by calling Member Services at 1‑888‑348‑2922; TTY: 711 between 8:30 a.m. and 5 p.m. (ET), Monday through Friday. After normal business hours, you may leave a message and someone will return your call the next business day. If a UM employee calls you, they will give you their name and title and say they are calling from Aetna Better Health. You can also access TTY services or language assistance to talk about UM issues.

Our UM program helps make sure you get the right services at the right place. When we make decisions, it's important for you to remember the following:• We make decisions by looking at your benefits and choosing the most appropriate care and service• We don't reward doctors or other people for denying coverage or care• Our employees do not get any incentives to reduce the services you get

Preauthorization is required before the date you get care for the care listed below:• Home based services• Rehabilitative Services: Physical, Occupational, or Speech Therapy• Durable medical equipment (DME)• Polysomnograms (Sleep Apnea Studies)• Genetic testing• Pain management services• Computerized Tomography (CT scan)• Magnetic Resonance Imaging (MRI)• Magnetic Resonance Angiogram (MRA)• Positive Emission Tomography (PET Scan)• Inpatient hospital care• Outpatient surgery• Intensive outpatient behavioral health services• Partial hospitalization• Psychiatric residential treatment facility care• Services from a non‑participating provider (except emergency services and family planning)

This list is not intended to be all inclusive. If you have any questions, call Member Services at 1‑888‑348‑2922.

Additional information about preauthorizationWe update the preauthorization list from time to time. If you are not sure about a certain service call Member Services at 1‑888‑348‑2922; TTY: 711.

“Carved-Out” servicesAs a member of Aetna Better Health, you may receive the following services through the Department of Health and Human Resources (DHHR):• Nursing facility services• Intermediate care facility services• Community care programs for the elderly• Transportation for things that are not an emergency• Hemophiliac Factors• Hepatitis C• Transplants• Prescription Drugs

If you need help receiving these services, just call Member Services at 1-888-348-2922.


Non‑emergent transportationNon‑emergent transportation is managed by MTM for the DHHR. If you need non‑emergent transportation, or gas mileage reimbursement, call MTM at 1‑844‑549‑8353.

If you have waited more than 15 minutes after the scheduled pick‑up time, call MTM's “Where's My Ride” line at 1‑844‑549‑8354 if you have waited more than 15 minutes after the pick‑up time. Call the same number if you have waited more than one hour after calling to schedule a return ride.

To file a complaint with MTM, call the MTM “We Care” line at 1‑866‑436‑0457. MTM follows up on all complaints.

Prescription drugsThe prescription drug benefit is administered by the State Medicaid program. For questions about getting your medicines you must call Molina at 1‑888‑483‑0797 between 7:00 a.m. ‑ 7:00 p.m. Monday through Friday

Third Party Liability (TPL)If you have received care due to an accident or work related injury, we will work with the other insurance companies or associates to make sure your claims are paid correctly. Call us at 1‑888‑348‑2922 to report any situation where you have received medical care following an accident, work related injury or any other situation where a different insurance company or legal counsel is involved.

Care away from homeIf you get sick while you are away from home, call your PCP or the 24‑Hour Informed Health Line.

Your PCP or a nurse can tell you what type of treatment you need and if you should see a practitioner. If you need treatment and are too far away to see your PCP within 24 hours, we will help you find a practitioner or urgent care center nearby.

If you have an emergency when you are away from your home, you can still call your PCP or the 24‑Hour Informed Health Line. They can help you decide what kind of treatment to get.

If you need emergency treatment and you are outside of the Aetna Better Health service area, you should go to the nearest urgent care center or hospital. Please let the hospital know that you are an Aetna Better Health member and have the hospital call Member Services at 1‑888‑348‑2922. If you are at a hospital that is not in the Aetna Better Health network, we may ask you to move to another hospital in our network when you are well enough to do so.

Reporting fraudulent activityIf you suspect any fraud or abuse, call 1‑844‑405‑2016 to report it.


Section 4Covered services and limitsAetna Better Health manages the benefits covered in this Member Handbook by:• Working with your practitioner to decide what care is needed.• Deciding what care is covered.• Interpreting this Member Handbook when there is a question about coverage.

Most care must be given by an Aetna Better Health of West Virginia practitioner or provider and done at an Aetna Better Health facility. The only exceptions will be if:• Your PCP asks for you to go out of the network and Aetna Better Health agrees and approves the service.• You receive family planning services.• You have an emergency.

We contract with a network of practitioners and providers for care. Sometimes there may not be an Aetna Better Health of West Virginia provider who can provide the care you need. If this happens, you may need to go out of the network for the care. We must approve this care before you go.

We will remain current with reviewing new technology to be included as a covered benefit. We will review medical literature to help pick the technologies that will provide medically needed care and is approved by any regulating body required by law to do so. The new technologies must show improvement in the health risk of a member over current products or procedures.

Care or supplies must be medically needed to be covered. Medical need is decided by looking at the generally accepted standards of care. We decide whether the care meets these standards.

We have special programs to help you with all your medical, behavioral, dental and social health care needs. We will work with you and your practitioner to help you get the best care.

Care ManagementSome members have special health care needs and medical conditions. Aetna Better Health Care Management includes nurses who work with many health care practitioners, agencies and organizations to get the services and the care that you need.

Our Care Management Program can help make sure you understand your condition and treatment plan. Our team of registered nurses and social workers receive training in the care management process. We will help you get the best care in the most efficient manner.

Care Managers have a variety of daily activities as they interact with everyone involved in your life. They coordinate care in the following ways:• Work one‑on‑one with you to create a plan based on your goals.• Review your plan to help make sure you do not have gaps in care.• Consult with your doctors.• Help you make specialist and primary care doctor appointments.• Verify that the right medicines and treatments are in place.• Help make sure you receive preventive care.• Work to ensure you and your family have the support you need.• Ask questions to make sure your home is safe.• Provide patient and family education about programs and services available in the community and through your

doctor.• Make sure you have support for any behavioral health needs.• Help you transition to other care when your benefits end, if necessary.

We have programs if you have a high‑risk pregnancy or substance abuse during pregnancy, have a baby needing neonatal intensive care (NICU), or if you need help transitioning your care from the hospital. These programs help you take good care of yourself.


Care Management has a list of community resources and services that can help with various needs. Care Management can help you find the available community services that are right for you.

We want to help you. To sign up, call us at 1‑888‑348‑2922 and ask to speak to a Care Manager. Your practitioner or caregiver can also call to sign you up for the program. You may join or leave the program at any time.

Disease ManagementOur Disease Management Program can help you better manage your health. We offer disease management programs for our members with asthma, diabetes, heart failure, coronary artery disease, depression and COPD (lung disease). These programs educate you on your disease and give you tips on how to stay healthy. We'll give you information to read and the names and phone numbers of resources to help you manage your disease. If you have one of these conditions, you will automatically be enrolled in the Disease Management Program. Your doctor can also ask us to enroll you in the program. Participating in the Disease Management Program is important for your health. You may leave the program at any time. To opt‑out call 1‑888‑348‑2922.

Behavioral Health care (mental health care/substance use disorder)If you are in a crisis situation and think you might hurt yourself or someone else, call 911.

Behavioral Health services can help you with personal issues that may affect you. Some examples are depression, anxiety or problems from using drugs or alcohol.

Your PCP may be able to help you with mild depression or anxiety. Your PCP may also help you with alcohol problems or attention deficit hyperactivity disorder (ADHD). PCPs may write prescriptions for drugs and check to see how the drugs are working for you. They can also order lab tests and other tests for Behavioral Health issues.

You do not need a PCP referral for Behavioral Health services. The services covered under Aetna Better Health are listed in the benefit tables for Mountain Health Trust and WV Health Bridge.

We encourage you to sign a release of information so that your PCP and Behavioral Health Practitioner may communicate with each other and provide the best care possible.

Chiropractic servicesChiropractic services are limited to spinal manipulation to correct subluxation only. Chiropractor services for some members are limited. Please contact Member Services at 1‑888‑348‑2922 to discuss your benefits. Radiological examinations are covered when related to the chiropractic service.

Court ordered servicesWe cover court‑ordered treatment services that are a covered benefit by WV Medicaid. The court ordered plan must be submitted for Pre Authorization to make sure it meets the medical necessity requirements under Aetna Better Health. If a service is denied, you can follow the member appeal process.

Dental services (child)Children up to 21 years of age are eligible for dental check‑ups. It is very important for members to have a dental checkup every 6 months. Other dental services covered for children include: restorative services, orthodontics, and other dental or oral surgery services needed to correct dental problems.

Under the BMS Infant and Child Oral Health Fluoride Varnish Program certified Primary Care Practitioners can provide fluoride varnish application. To find out more about this ask your child's practitioner.

Orthodontic services will be completed in‑full regardless of a member's enrollment or eligibility.

We cover anesthesia for dental services when the service is in the outpatient hospital or inpatient hospital. Anesthesia for dental services requires preauthorization approval.

Scion Dental will be the dental provider for Aetna Better Health of West Virginia children. If you need to talk to Scion Dental, call Scion Dental Customer Service at 1‑888‑983‑4693, TTY: 1‑800‑508‑6975.


Dental services (adult)We cover certain emergent adult dental services (anyone 21 years of age and older). We also cover up to two preventive dental visits during pregnancy.

Examples of emergent dental services include:• Removal of an abscess tooth• Removal of a tumor or treatment of a fracture• Treatment of infection• Up to two preventive dental visits during pregnancy

Emergency dental services provided by a dentist or oral surgeon that provides care to WV Medicaid members are covered. If you have questions call Member Services at 1‑888‑348‑2922; TTY: 711.

Oral surgery including dental accidentsWe cover oral surgery only for the cases below. Your PCP must send you for the care. We must preauthorize the care. Aetna Better Health of West Virginia benefits only cover repairs needed for daily living.

Covered services:• Oral surgery for non‑dental surgical and hospital procedures for birth defects (like cleft lip and cleft palate).• Medically needed medical or surgical procedures within or next to the oral cavity or sinuses.• Medically needed dental services due to an accidental injury when your practitioner submits a plan of treatment

to us. The medical service must be performed within six months of the injury.• Medically needed medical or surgical procedures within or next to the oral cavity or sinuses resulting from the

removal of tumors and cysts.

Not covered:• Cosmetic services or repairs Aetna Better Health decides are not needed for daily living.• Other procedures involving the teeth or areas around the teeth including but not limited to:

– Shortening of the mandible or maxilla for cosmetic purposes.– Correction of malocclusion or mandibular retrognathia.– Treatment of natural teeth due to diseases.– Repair, removal or replacement of sound natural teeth.– Diagnosis and treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Durable Medical Equipment (DME) and medical suppliesWe cover renting medically needed DME. Sometimes we will cover buying DME, but you must check first. Fixing or replacing damaged or lost equipment is covered. You must get the equipment from a provider in the Aetna Better Health of West Virginia network. We must preauthorize all rentals and some DME purchases.

Covered DME includes, but is not limited to:• Hospital beds and accessories• Wheelchairs and accessories• Oxygen and oxygen equipment• Apnea monitors; CPAP machines• Blood glucose meters• Prosthetic devices ‑ like an artificial arm or leg• Renal dialysis equipment and supplies• Orthotics• Insulin pumps and supplies• Ostomy supplies

Not covered:• Space‑conditioning equipment, such as room humidifiers, air conditioners, and air cleaners• Furniture or appliances not defined as medical equipment• Items that are only for the member's comfort and convenience or for the convenience of those caring for the

member


• Home or vehicle modifications• Equipment for which the primary function is vocationally or educationally related• Non‑compression type support stockings

Early and Periodic Screening, Diagnosis and Treatment (EPSDT)All children are given the care needed to promote health through the EPSDT (Early and Periodic Screening, Diagnosis and Treatment) Program. We offer eligible members under 21 years of age EPSDT services at no cost. Under Medicaid, your child may be eligible to receive certain services not covered under EPSDT.

EPSDT covers medically necessary services to cure an illness or condition or at least keep it from getting worse. These benefits include, but are not limited to, services for nursing care, individualized treatments specific to developmental issues and accessing “Carved‑Out” services.

EPSDT allows children regular check‑ups and the care needed when sick. Your child will get both sick and well care from the same practitioner through this program. This will help your child get to know his or her PCP and help your practitioner keep a complete record of your child's health.

The PCP will give your child check‑ups and will help plan the care needed to prevent illness. Your child needs to have routine checkups. Routine checkups help catch health problems before they are serious. These checkups include dental, vision and hearing screenings and shots. Aetna Better Health of West Virginia benefits cover follow‑up treatment and testing when screenings find health problems.

A complete physical exam includes:• Physical, Behavioral Health, and developmental history.• An unclothed physical exam.• Lab tests (including hematocrit/hemoglobin, urinalysis, and blood lead toxicity screening).• Immunizations (shots).• Nutritional assessment.• Injury prevention discussions.• Checking and counseling about the growth and development of your child.• Vision, hearing and dental screens.• Dental services (furnished by a direct referral to a dentist for children beginning 6 months after the first tooth

erupts or by 12 months of age). We cover dental screenings for any child under the age of 21 years per the recommended guidelines set forth by the American Academy of Pediatric Dentistry (AAPD) and Bright Futures.

Newborns receive their first hearing screening before leaving the hospital after birth. Follow‑up visits to an Aetna Better Health of West Virginia audiologist to determine whether the child has hearing loss are also covered. Newborns that missed a first hearing screening at the hospital after birth may go to an Aetna Better Health of West Virginia audiologist for the screening and any needed follow‑up visits.

For patients at risk, a screening may also include the following procedures:• Tuberculin test (at age 9 months, age 15 months and at each EPSDT screening thereafter)• Cholesterol screening beginning at age 24 months• Screening for Sexually Transmitted Diseases beginning at age 12• Pelvic exam beginning at age 12


Children should get checkups regularly, at the ages listed below:

Sick visits do not take the place of a routine screening visit.Children need shots to help their body fight disease. Each shot fights a different disease. Children must have a record of these shots in order to begin school. You may need to provide this record when you enroll your children into school.

Children should get each shot at the ages given in the chart below. Some shots need to be given more than once.

Age ShotShortly after birth Hepatitis B #1 Between 1 and 2 months Hepatitis B #2 2 months Diphtheria, tetanus, acellular pertussis (DTaP)

H. influenzae type B (Hib) Inactivated P\poliovirus (IPV) Pneumococcal conjugate (PCV) Rotavirus

4 months Diphtheria, tetanus, acellular pertussis (DTaP) H. influenzae type B (Hib) Inactivated poliovirus (IPV) Pneumococcal conjugate (PCV) Rotavirus

Between 6 and 18 months Hepatitis B #3 Inactivated poliovirus (IPV)

At 6 months then yearly to 18 years Influenza (Flu) – annually 6 months Diphtheria, tetanus, acellular pertussis (DTaP)

H. influenzae type B (Hib) Pneumococcal conjugate (PCV) Rotavirus

Between 12 and 15 months H. influeneza type B (Hib) Measles, mumps, rubella (MMR) Pneumococcal conjugate (PCV) Varicella (chickenpox)

Between 12 and 23 months Hepatitis A #1 and hepatitis A #2 Between 15 and 18 months Diphtheria, tetanus, acellular pertussis (DTaP)After 2 years of age for certain high‑risk groups Pneumococcal Polysaccharide (PPV)

Meningococcal Conjugate (MCV) HepA Series

4 to 6 years Diphtheria, tetanus, acellular pertussis (DTaP) Inactivated poliovirus (IPV) Measles, mumps, rubella (MMR) Varicella (chickenpox)

Age1 Week1 Month2 Months4 Months6 Months9 Months

Age12 Months15 Months18 Months24 Months30 MonthsEvery year between ages 3 and 21 years


Age Shot10 to 12 years Diphtheria, tetanus, acellular pertussis (DTaP)

Meningococcal conjugate 11 to 12 years Human papillomavirus (HPV) 3 doses 13 to 18 years Human papillomavirus (HPV) series, if did not already

received

Eye care and eye glassesWe cover certain vision services for adults and children when done by an Aetna Better Health practitioner or a Vision Service Plan (VSP) practitioner. A VSP practitioner should provide routine vision care. Call us to find out how to get care from an Aetna Better Health of West Virginia or VSP practitioner nearest you. You can also go to www.aetnabetterhealth.com/westvirginia or look in your Aetna Better Health Provider Directory.

Covered services:Full vision care benefits are available for Medicaid members under 21 years of age. Limited vision care benefits are available for members 21 years and older. Covered vision care includes services for examination, diagnosis, treatment and management of ocular and adnexal pathology. This includes diagnostic testing, treatment of eye disease or infection, specialist consultation and referral, comprehensive ophthalmologic evaluations, and eye surgery (non‑cosmetic). Visual examinations to determine the need for eyeglasses are covered for children only.

Yearly diabetic eye exams are a covered me0dical benefit. Make an appointment with an optometrist or ophthalmologist from the specialist section of your Aetna Better Health of West Virginia Provider Directory. Let the practitioner know that you are a diabetic and need this special eye exam.

Limits:• One complete replacement pair of eyeglasses a year due to breakage or loss for members under 21 years of age.• Replacement frames or lenses for specific criteria for members under 21 years of age.• The first pair of eyeglasses for members 21 years and over following cataract surgery.• Eye exercises (orthoptics) for members under 21 years of age.• Contact lenses for the diagnosis of aphakia, keratoconus, aniseikonia, and anisometropia for members under 21

years of age.• Contact lenses for the diagnosis of aphakia and keratoconus for members 21 years and older.• Photochromatic lenses for albinism only (members under 21 years of age).

Exceptions:• Non‑routine eye exams are not limited to a 24‑month time frame.• The member must pay upgrades and add‑ons. These services are not covered and payment is between the

member and the practitioner.

Not covered:• For adults, lenses, frames or repair of glasses, contact lenses (unless associated with aphakia or keratoconus).• Visual augmentation devices.

Family planning services and suppliesFamily planning helps you plan your family size. It gives you information on birth control methods. Family planning is covered for Aetna Better Health of West Virginia members of child‑bearing age. Any care given is kept private. You do not need to ask your PCP before getting this care. If you do not want to talk to your PCP about family planning, call us at 1‑888‑348‑2922; TTY: 711. We will help you pick a family planning practitioner. You may pick a family planning practitioner and get covered family planning services and supplies from an Aetna Better Health of West Virginia practitioner or a practitioner outside the network.

Covered services:• Family planning office visits.• Tubal ligations.• Depo‑Provera injections.


• Diaphragm.• IUD.• Vasectomies.• Education and counseling.• Diagnostic procedures and lab tests.

Limits:Aetna Better Health of West Virginia benefits cover sterilization of an adult member (over 21) only when:• The member completes the sterilization consent form provided by the practitioner.• The member is mentally competent.

Not covered:• Hysterectomies performed solely for the purpose of rendering an individual incapable of reproducing.• Treatment of infertility or services to promote fertility.

High-risk prenatal servicesAetna Better Health's Prenatal Service Program provides care management for high‑risk members who are pregnant. Through risk screenings, your practitioner and Aetna Better Health work together to decide which members need these extra services.

Covered services:• Patient education classes.• Nutrition assessment and counseling by a registered dietitian.• Coordination of community resources for classes such as childbirth and parenting.• Follow‑up monitoring that the member is actually getting the care needed.• Guidance and support for the member through the process.• Blood Glucose meters.• Testing for HIV.

Home health careA licensed or certified nurse or other health care practitioner may provide care for you in your home. Care is provided in your home when medically necessary. Aetna Better Health must preauthorize the care. We decide what is appropriate by reviewing this care together with your practitioner.

Covered services:• Nursing services.• Home Health Aide services when considered medically needed (assisting with personal hygiene, eating, walking,

meal preparation and feeding, taking and recording blood pressure, pulse and respiration).• Therapy services.• Medical supplies.

Limits:• Licensed nurse visits must be medically necessary and preauthorized.• Therapy visits are preauthorized based on medical necessity and a therapy plan of care.

Inpatient hospital careWhen you do not have an emergency, we must preauthorize your stay before you go to the hospital. You must go to a hospital that is an Aetna Better Health of West Virginia provider. You will be under the care of your PCP or other practitioner to whom your PCP has sent you.

We help manage all hospital stays. We look at the care you get while you are in the hospital. The care is covered as long as there is a medical need for the care. If all or part of the hospital stay is not medically needed, your practitioner will be told that coverage will end and you will not be responsible for payment.

Covered services:• Semi‑private room and board• Medical supplies


• X‑ray, lab, diagnostic/therapeutic services• Use of hospital facilities• Drugs and biologicals• Nursing care• Physical therapy• Radiation therapy• Renal dialysis• Chemotherapy• Intravenous therapy• Inhalation therapy• Occupational therapy• Speech and hearing services• Newborn infant care including hearing screenings• Administration of whole blood and blood plasma• Supplies, appliances and equipment needed to provide appropriate care and treatment

Not covered:• Any services that are not medically needed• Cosmetic surgery done only to make you look better• Elective surgery, which is not medically needed to restore or improve a body function. This includes surgery for

breast reduction.• Supplies and devices that are for comfort or convenience only (like radio, TV, phone and guest meals); private

rooms, unless a private room is medically needed or a semi‑private room is not available. If you stay in a private room, it must be preauthorized by Aetna Better Health during your hospital stay.

MaternityMaternity is pregnancy care, including prenatal, inpatient hospital stay during delivery and post‑partum care. Take good care of yourself and your baby. See your practitioner as soon as you know you are pregnant. Your practitioner will notify Aetna Better Health about your pregnancy and we will send you information about our pregnancy program and how you can participate.

Not covered:• Home birth

Nurse midwifeUnder the Federal Medicaid Program, you may use certified nurse midwives, certified pediatric nurse practitioners or a family nurse practitioner who are contracted with us to give you medical care. You may receive care in the practitioner's office, a hospital, a clinic or any other place needed to treat an illness, injury or condition. Check your Provider Directory or call us at 1‑888‑348‑2922 for more information.

Not covered:• Home birth

Outpatient hospital careOutpatient hospital care includes:• Care to prevent sickness.• Tests to find sickness.• Care to help you heal.

You should tell your PCP when you receive outpatient hospital care. We must preauthorize this care. You can get the care at hospital outpatient departments, clinics, health centers or practitioners' offices that are in the Aetna Better Health of West Virginia Provider Directory.


Covered services:• Physical, occupational and speech‑language pathology therapy• Hematology• Chemistry• Renal dialysis• Chemotherapy• Radiation therapy• Intravenous therapy• Inhalation therapy• Diagnostic x‑rays• Isotope studies• EKG and pulmonary services• Thyroid function test• Emergency room• Medical supplies (e.g. oxygen and splints)• Special therapy treatments• Outpatient surgery room• 48‑hour observation stays

Not Covered:• Acupuncture

Practitioner servicesWe cover care given by a licensed Aetna Better Health of West Virginia practitioner. You may receive care in the practitioner's office, a hospital, a clinic, or any other place needed to treat an illness, injury or disease. You may also receive care at these places for family planning, maternity care, and well‑child screenings under the EPSDT program or other preventive care. Regular health exams are covered for adults.

Covered services:• Anesthesia• Office visits• Chemotherapy• Concurrent care• Consultations• Referrals• Treatment for End‑Stage Renal Disease• Eye care• Hospital visits• House calls• Therapeutic injections• Lab and x‑rays• Routine screenings (Prostate‑Specific Antigen (PSA) testing, rectal examinations, colorectal cancer screening,

pap smear and mammography)• Disposable medical supplies normally used in practitioner's office; routine newborn care• Newborn circumcision• Physical therapy• Medically needed surgical procedures• Assistant surgeons• Diagnostic surgical procedures (biopsy and endoscopy)• Preoperative and postoperative care related to surgery

Limits: • Routine screenings are provided according to most recent guidelines.


Not covered:• Cosmetic surgery done only to make you look better.• Elective surgery, which is not medically needed to restore or materially improve a body function. This includes

surgery for breast reduction.• Services which are experimental/investigational.• Exams needed only for insurance, employment, sports or camp that are not part of a covered routine health

assessment.• Shots needed for travel, school and work that are not part of the recommended immunization schedule.

Members may access an out‑of‑network network provider that is the main source of a service for the first 90 days of enrollment to complete an ongoing course of treatment. This must be pre authorized by us.

Second medical opinionYou may need a second opinion for an illness, surgery and/or confirming a treatment of care your practitioner has told you that you need. Contact your practitioner or Member Services for help to get a second opinion. If an appropriate provider for the second opinion is not available within the Aetna Better Health network, we will arrange for you to get the second opinion outside the network. There is no cost to you for the second opinion.

Sexually transmitted disease treatmentTreatment for a sexually transmitted disease is a covered benefit. You may receive services to treat a sexually transmitted disease from your PCP or any in‑network specialist.

Therapy servicesPhysical therapy, occupational therapy and speech therapy are based on medical necessity, a practitioner's order and a treatment plan of care.

Urgent careUrgent care is medically needed care for an unexpected illness or injury that you need sooner than a routine practitioner's visit. Your PCP can help you determine whether you need to receive urgent care. If you have a true emergency, go to the hospital emergency room.

Vision servicesFull vision care benefits are available for members under 21 years of age. Limited vision benefits are available for members 21 years old or over.

Vision coverage for members under 21 years of age include one comprehensive eye exam, one set of frames and one set of lenses each calendar year. We may cover contact lenses for specific conditions for members younger than 21 years of age.

We may cover contact lenses for members over 21 years of age for the specific conditions of aphakia and keratoconus.

Well‑care servicesWell‑care services help members to stay healthy and avoid some illnesses. Some examples of well‑care services are annual check‑ups, immunizations (shots) for children, mammograms for women and prostate exams for men. Your PCP should provide or schedule most of the well‑care services you receive.

Women's health care servicesWomen's health care services are direct access services to an OB/GYN for care of or related to the female reproductive system. You do not need a referral or preauthorization for these services if you see a participating practitioner.

Covered services:• A yearly gynecological exam for female members, age 13 or older, which includes:

– Breast exam– Pelvic exam– Annual Pap smear, when done by an Aetna Better Health of West Virginia practitioner


• Screening mammograms using the following schedule: One baseline screening for ages 35 to 39; one mammogram annually for ages 40 and over.

• Prenatal care. We will recommend that the mother have HIV testing, which is covered.• Services to treat any medical condition that may complicate pregnancy.• Pregnancy‑related and postpartum services for 60 days after the pregnancy ends.• If a newborn and mother or newborn alone are released from the hospital less than 48 hours after the day

of delivery, at least one follow‑up visit will be covered. The follow‑up visit will be given within 48 hours after release. The visit will meet the most recent “Guidelines for Perinatal Care” developed by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. It will also meet the “Standards for Obstetric‑Gynecologic Services” prepared by the American College of Obstetricians and Gynecologists.

• Hysterectomies when medically needed.• Prostheses needed after the medically needed complete or partial removal of a breast for any medical reason.• Reconstructive breast surgery performed along with, or after a full or partial mastectomy. Inpatient hospital care

is covered for at least 48 hours after a radical or modified radical mastectomy. Inpatient hospital care is covered for at least 24 hours after a total mastectomy or a partial mastectomy with lymph node dissection. Inpatient hospital care for lengths stated above can be shorter if you and the practitioner treating you both agree on the shorter stay.

Limits:• We cover reconstructive breast surgery when it is done along with a full or partial mastectomy.• Reconstructive breast surgery is also covered for the non‑affected breast after a full or partial mastectomy to

regain symmetry between the two breasts.

Not covered:• Hysterectomy done solely to make the member not be able to reproduce.

Mountain Health Trust & West Virginia Health Bridge Covered BenefitsMedical • Primary Care Office Visits and Referrals to Specialists • Physician Services – Certain services may require prior authorization or have service limits. May be delivered

through telehealth. • Laboratory and X‑ray Services – Includes lab services related to substance abuse treatment. Services must be

ordered by a physician, and certain procedures have service limits. • Clinics – Includes general clinics, birthing centers, and health department clinics. Vaccinations are included for

children. Specialty • Podiatry – Includes treatment of acute conditions for children and adults. Includes some surgeries, reduction of

fractures and other injuries, and orthotics. Routine foot care is not covered. • Physical Therapy – 30 visits per year for habilitative and rehabilitative services (combined for physical and

occupational therapy).• Occupational Therapy – 30 visits per year for habilitative and rehabilitative services (combined for physical and

occupational therapy).• Speech Therapy – Habilitative and rehabilitative services including hearing aid evaluations, hearing aids and

supplies, batteries, and repairs (not covered for adults in Mountain Health Trust). Some procedures have service limits or require prior approval.

• Handicapped and Children with Special Health Care Needs Services – Includes coordinated services and limited medical services, equipment and supplier (for children only).

• Chiropractor Services – Includes radiological exams and corrections to subluxation. Certain procedures have service limits.

Emergency • Post‑stabilization Services – Includes care after an emergency health condition is under control. Care provided

in a hospital or other setting. • Emergency Transportation – Includes ambulance and air ambulance. Out of state requires prior authorization.

To call for Emergency Transportation, dial 911.


Preventive Care and Disease Management • EPSDT – Includes health care services for any medical or psychological condition discovered during screening

(for children only). • Tobacco Cessation – Includes therapy and counseling and Quitline services. Guidance and risk‑reduction

counseling covered for children. • Diabetes Care – includes assessments of diabetes, diet management and education, and referral to other

providers.• Sexually Transmitted Disease Services – Includes screening for a sexually transmitted disease from your PCP or

a specialist in our network. Maternity• Right From The Start – Includes prenatal care and care coordination. No prior authorization required. • Family Planning – Includes all family planning providers and services. Sterilizations, hysterectomies, pregnancy

terminations, and infertility treatments are not covered. No referral needed for out‑of‑network providers. • Maternity Care – Includes prenatal, inpatient hospital stays during delivery, and post‑partum care. Home birth

is not covered.Other • Federally Qualified Health Centers – Includes physician, physician assistant, nurse practitioner, and nurse

midwife services. • Prosthetics – Customized special equipment is considered. Certain procedures have services limits or require

prior authorization. • Durable Medical Equipment – Covered in nursing facilities and ICF/MRs. Customized special equipment is

considered. Certain procedures have services limits or require prior authorization• Ambulatory Surgical Care – Includes services and equipment for surgical procedures. Physician services; lab

and x‑ray; prosthetic devices; ambulance; leg, arm, back, and neck braces; artificial limbs; and durable medical equipment not covered.

Nursing • Nurse Practitioner Services – Some procedures have service limits. • Private Duty Nursing – Includes 24‑hour nursing care (not covered for adults in Mountain Health Trust). Prior

approval may be required.

Rehabilitation • Pulmonary Rehabilitation – Includes procedures to increase strength of respiratory muscle and functions.• Cardiac Rehabilitation ‑ Includes supervised exercise sessions with electrocardiograph monitoring. • Inpatient Rehabilitation – Includes inpatient rehabilitation services and general medical outpatient services

that meet the certification requirements. Not covered for adults under Mountain Health Trust. Hospital • Inpatient – Includes all inpatient services. Transplant services must be in a center approved by Medicare

and Medicaid. Adults in institutions for mental diseases and some behavioral health inpatient stays are not included.

• Outpatient – Includes preventive, diagnostic, therapeutic, all emergency services, and rehabilitative medical services.

Home Health Care – Includes services given at member’s residence. This does not include a hospital nursing facility, ICF/MR, or state institutions. Some suppliers have service limits. Hospice – Includes nursing care, physician services, medical social services, short‑term care, durable medical equipment, drugs, biologicals, home health aide, and homemaker. Requires physician certification. For adults, rights are waived to other Medicaid services related to the terminal illness. Dental – Includes emergency, non‑emergency, and orthodontic services for children. Includes treatment of fractures, biopsy, tumors, and emergency extractions for adults. TMJ is not covered for adults.


Behavioral Health • Behavioral Health Rehabilitation/ Psychiatric Residential Treatment Facility – Includes services for children with

mental illness and substance abuse. Limits frequency and amount of services. • Inpatient – includes behavioral health and substance abuse hospital stays • Inpatient Psychiatric – Includes treatment through an individual plan of care. Pre‑ admission and continued

authorization is required. Certification required. Not covered under West Virginia Health Bridge. • Outpatient – Includes services for individuals with mental illness and substance abuse. Limits frequency and

amount of services. Providers must be ACT certified. Children’s residential treatment is not covered. • Psychological Services – May be delivered using telehealth. Some evaluation and testing procedures have

frequency restrictions. Vision – Includes eye exams, lenses, frames, and repairs for children. Includes medical treatment, one pair of glasses after cataract surgery, and contact lenses for adults. Does not cover prescription sunglasses or designer frames.

Be sure to use your regular Medicaid card for services that are not covered by Aetna Better Health.

Benefits Under Fee-for-Service MedicaidAbortion – Includes drugs, devices, and procedures for termination of ectopic pregnancy. Physician certification required. Early Intervention Services for Children Three and Under Nursing Facility Services – Includes nursing, social services, and therapy Personal Care Services – Includes personal hygiene, dressing, feeding, nutrition, environmental support, and health‑related functions. Room and board services require physician certification. May not exceed 60 hours per month without prior authorization. Personal Care for Aged/Disabled – Includes assistance with daily living in a community living arrangement, grooming, hygiene, nutrition, physical assistance, and environmental for individuals in the Age/ Disabled Waiver. Limited on per unit per month basis. Requires physician order and nursing plan of care. ICF/MR Intermediate Care Facility – Includes physician and nursing services, dental, vision, hearing, lab, dietary, recreational, social services, psychological, habilitation, and active treatment for the mentally retarded. Requires physician or psychiatrist certification. Prescription Drugs – Includes dispensed on an ambulatory basis by a pharmacy, family planning supplies, diabetic supplies, vitamins for children, and prenatal vitamins. Hemophilia blood factor, Hepatitis‑C, weight gain, cosmetic, hair growth, fertility, less than effective, and experimental drugs are not covered. Drugs dispensed by a physician at no cost are not covered. Organ Transplant Services – Generally safe, effective, medically necessary transplants covered when no alternative is available. Cannot be used for investigational/ research nature or for end‑stage diseases. Must be used to manage disease. School-based Services – Service limitations are listed in the fee for service Medicaid provider manual. Transportation – Includes multi‑passenger van services and common carriers (public railways, buses, cabs, airlines, and private vehicle transportation). Prior authorization is required by county DHHR staff. To get transportation, call: 1‑844‑549‑8353.

Member co-paymentsSome services require the member to pay a co‑payment. Co‑payments are based on the member's household income. The chart below lists the co‑payments the member needs to pay for each service. The co‑payment amount may be different for each Federal Poverty Level (FPL).


Medical co-payments table

Service TIER 1 Up to 50.00% FPL

TIER 2 50.01-100.00% FPL

TIER 3 100.01% FPL

and aboveInpatient Hospital (Acute Care 11x) $0 $35 $75Office Visit (Physicians and Nurse Practitioners)(99201‑99205, 99212‑99215 only for office visits with new and established patients based on level of care.)

$0 $2 $4

Non‑Emergency use of Emergency Department – Hospital only (Lowest level (99281) of Emergency Room visits in hospitals. The definition of an emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and straightforward medical decision making.)

$8 $8 $8

Any outpatient surgical services rendered in a physician’s office, Ambulatory Surgery Center or Outpatient Hospital excluding emergency rooms.

$0 $2 $4

Maximum Out of Pocket (OOP)Each calendar year quarter, Medicaid members will have a maximum OOP payment. The OOP is the most the member will be required to pay in any given quarter regardless of the number of health services they receive. See the table below for details.

Out of Pocket maximum table

Tier Level Out of Pocket Maximum1 (Up to 50.00% FPL) $82 (50.01‑100.00% FPL) $713 (100.01% FPL and above) $143

Co‑payments will not be collected for:• Family planning services• Emergency services• Behavioral health services• Members under age 21• Pregnant women (including 60 days after pregnancy)• American Indians and Alaska Natives• Members receiving hospice care• Members in nursing homes• Other members or services not under the State Plan authority• Members who have met their household maximum limit for cost‑sharing per calendar quarter• Members with primary insurance other than Medicaid

For more information on co‑payment amounts, please call Member Services at 1‑888‑348‑2922; TTY 711.


Section 5Emergency servicesYou and your family need to know what to do in an emergency. Learn the difference between an emergency and urgent care. Only very serious health problems should bring you to an emergency room. Learn what you should do in each case. Carry your Aetna Better Health ID card with you at all times.

You can find a list of hospitals that provide emergency services and post‑stabilization care in your Provider Directory. You can also call Member Services at 1‑888‑348‑2922; TTY: 711.

What is an emergency?Emergency care is care that you need right away. An emergency means your life could be threatened or you could be hurt permanently (disabled) if you don't get care quickly. If you are pregnant, it could mean harm to the health of you or your unborn baby. You do not have to go to an Aetna Better Health provider in an emergency. However, if you are in the service area, you can only go to a provider who is not in the Aetna Better Health provider network when the delay in getting care from an Aetna Better Health provider could reasonably be expected to cause your condition to worsen if left unattended. When you are told you need emergency care by either your PCP or by us, we will pay for the medical screening exam and any other medically necessary emergency services rendered in the hospital emergency room. Some examples of an emergency are:• Trouble breathing• Poisoning• Broken bones• Chest pain• Unconsciousness (blacking out)• Severe or unusual bleeding

• Convulsions or seizures• Sudden onset of severe pain• Any vaginal bleeding in pregnancy• Severe burns• Immediate and imminent threat to life or loss of life

due to a psychiatric illness or substance use

If you need emergency care, and do not have immediate access to a hospital or practitioner, you should call 911.

In the service area:If you have an emergency, you may not have time to call your PCP. If you do have time to call, he or she will help you decide what to do. If it's after your practitioner's regular office hours, you should call the after‑hours number for your practitioner. Keep this number in a place you can get to quickly when you need it. Your PCP or a practitioner on call for your PCP can be reached 24 hours a day.

If you need an ambulance for an emergency, call 911. We cover ambulance service only when there is an emergency or when we have preauthorized it. You should only use hospital emergency rooms that are not in the Aetna Better Health network when the delay of a longer travel time to a hospital within our network could reasonably be expected by a prudent layperson to cause your condition to worsen if left unattended.

If you must stay in the hospital after an emergency, your provider must call us within 24 hours or by the end of the next working day if the 24‑hour deadline falls on a weekend or legal holiday.

Outside the service area:If an emergency occurs while you are out of the service area, seek care. If you need to go to a hospital, call us within 24 hours or by the end of the next working day if the 24‑hour deadline falls on a weekend or legal holiday. You may need to keep getting care while you are out of the service area. You must get follow‑up visits preauthorized before you go back for any follow‑up visits. Call Member Services at 1‑888‑348‑2922; TTY: 711 to tell us what care you need. We can work with you and your health care practitioners to review the care you need for preauthorization. However, we will not preauthorize ongoing care out of the service area when you are able to come back to the service area for the care you need.


Show your Aetna Better Health ID card to the health care providers and ask that they file the claims with us. In some cases you may be asked to pay for emergency care. If this happens, you can send a statement that shows what care you got and a receipt for the payment of services. We will pay you back for covered emergency care when you were required to pay the providers. Be sure to give us your name, member number and a short statement about what happened.

You will never need a referral to go to an emergency room.

Payment for emergency servicesIn some cases, we may pay a participating provider a reduced fee for emergency services. When we pay a reduced fee, you are not responsible for any of the emergency facility or practitioner charges.

Post stabilization careThis is medically needed care a member gets after an emergency condition has been stabilized. We do not require preauthorization for post stabilization care.

Section 6General services not coveredIf a procedure, service or supply is denied, you or your practitioner has the right to request an appeal by sending a request to our Aetna Better Health Appeals Department. We describe this process in Section 7 of this Handbook.

The following services are not covered:• Breast implants for cosmetic purposes.• TMJ and other dental problems related to malocclusion unless proven to be life‑threatening.• Nonmedical treatment including special education and training for learning disabilities, behavioral disorders or

the mentally challenged.• Custodial or certain home care, rest and respite care, and personal comfort items (to include cleansing and

luxury items); self‑care or self‑help training.• Health care services which have been interpreted by Aetna Better Health as experimental or investigational

through a review of the standards of the AMA, FDA, NIH or Medicare.• Medical services based on religious beliefs.• Private hospital rooms, personal or comfort items and services like guest meals and lodging, radio, television and

telephone.• Hospital or medical care for problems that state or local law requires treatment in a public facility.• Any injury or sickness when benefits, settlement, award, or damages are received or paid; this includes workers'

compensation, employer's liability, similar law or act, or other insurance.• Reversal of voluntary sterilization.• Sterilization for members under age 21; sterilization of a mentally incompetent or institutionalized person.• Sex change procedures/expenses.• If you are outside of the service area and you seek care at a nonparticipating facility, once you become stable and

are able to be transferred to a participating facility, if you refuse the transfer to the participating facility, then the stay at the nonparticipating facility will not be covered.

• If you are given medical direction from a participating practitioner due to health reasons not to travel due to a specific health reason, any care received while traveling outside of the Aetna Better Health service area due to that health problem will not be covered.

• Routine foot care without a medical diagnosis of diabetes, treatment of flat foot, trimming of corns, calluses, nails and subluxations of the foot.

• Supplies, items or equipment determined to be nonmedical in nature.• Care of military service‑connected conditions for which the member is legally entitled to services and for which

facilities are reasonably accessible to the member. Services received in veterans or other federal hospital, or care for conditions that federal, state or local law requires are treated in a public facility or any service received for which a covered person has no responsibility to pay.

• Sport‑related devices.


• Acupuncture, acupressure, massage therapy, hypnosis or electrolysis.• Services by a practitioner with the same legal residence or is related to a member.• Unlicensed services by a practitioner.• War‑related injuries, treatment in a state or federal hospital for military or service related injuries or disabilities.• Hospital and medical services not medically necessary or appropriate as determined by Aetna Better Health.• Inpatient hospital tests not ordered by the attending practitioner or other licensed practitioner, except in cases of

emergency.• Replacement and/or repair of DME, orthotic and prosthetic devices due to misuse or abuse.• Sexual counseling services provided to treat conditions that are not producing significant physical or mental

symptoms.• Medical and surgical treatment for all infertility services.• Liposuction, pannuculectomies or abdominoplasty, to treat obesity, unless medically necessary.• Work‑hardening programs.• Services provided by weight loss clinics and diet centers, enrollment in a health, athletic or similar club or in a

weight loss or similar program.• Care for conditions for which a member refuses to follow a recommended treatment or procedure when a

participating practitioner believes that no professionally acceptable alternative exists, provided that the member has been so advised and upon being so advised, still refuses to follow the recommended treatment or procedure.

• All health services rendered during a member's incarceration in any jail, prison or other correctional facility, excluding inpatient stays over 24 hours that meet for medical necessity.

• Health services prohibited by law or regulation.• Health services or supplies from nonparticipating practitioners, except in an emergency, for family planning or

when otherwise approved by Aetna Better Health.• Health services for which claims were filed by provider more than one year from the date of services.• Exams precedent to engaging in recreational activities, or for employment, insurance, administrative

proceedings, research or any type of license required by local state or federal law, unless obtained in the context of the periodic physical exam.

• Cosmetic, reconstructive or plastic surgery done primarily to change or improve the appearance of any portion of the body, including but not limited to treatment of obesity (except those services encompassed in the Women's Health and Cancer Rights Act and the Women's Access to Health Care Law which require preauthorization).

Section 7Complaints, Appeals and State Fair HearingsYour satisfaction is important to us. In order to meet your needs we have procedures in place for complaints, grievances and appeals. You may use the complaint, grievance and appeal procedures if:• You do not agree with the way we interpret this Handbook.• The quality and speed of service does not meet your needs.• You do not agree with our decision not to preauthorize care.• You are not happy with a practitioner assigned to you.• You suspect Medicaid fraud or abuse.

If you are hearing impaired, or if you do not speak English or have a limited understanding of English, we will provide oral language services. Language services include answering questions and providing help with filing claims, benefit requests, and filing appeals. The language service can also provide written interpretation of a written appeal request that we may receive in a language other than English.

Call us anytime at 1‑888‑348‑2922; TTY: 711.


ComplaintsAs a member of Aetna Better Health of West Virginia, you have the right to file a complaint at any time. You can file a complaint if you are unhappy with something about Aetna Better Health of West Virginia or one of our practitioners or providers. You can also file a complaint if you disagree with our decision about your appeal. To file a verbal complaint call us at 1‑888‑348‑2922. You can also file a written complaint, or allow someone like your PCP to do so on your behalf. If you choose to write to us, you will need to include your address.

To file a written complaint, please mail a letter to:

Aetna Better Health of West VirginiaAttn: Member Complaints500 Virginia Street, EastSuite 400Charleston, WV 25301

You will get an answer within 30 calendar days from the date your complaint is received. If it is in your interest, you can ask for a delay in our decision for up to 14 days. If we need to delay our decision for another reason, we will give you written notice within two calendar days.

If you need help with a complaint, you can call Member Services toll‑free at 1‑888‑348‑2922. We can assist you in completing forms. We also can offer auxiliary aids, interpreters, and other services.

At any time, you can file a complaint to West Virginia's Bureau for Medical Services:Bureau for Medical Services350 Capitol StreetRoom 251Charleston, WV 25301(304) 558‑1700

AppealsAs a member of Aetna Better Health of West Virginia, you have the right to appeal a decision, including non‑coverage decisions. You can file an appeal if you do not agree with our decision about your service authorization or prior authorization request. Our decision to reduce, suspend, or stop services will be sent to you in a Notice of Action letter. You will have 60 calendar days from the date of the Notice of Action to file an appeal with Aetna Better Health of West Virginia. If you would like your benefits to continue while the appeal is pending, you or your provider must file a request within 10 calendar days of date on the Notice of Action letter. You can file an appeal by calling Member Services at 1‑888‑348‑2922 or you can do so in writing. All verbal appeals must be followed up in writing. With written consent, you can also have someone else, like your PCP, a family member, friend or attorney, file an appeal on your behalf.

To file an appeal you will need to send us a letter that has:• Your name.• Your practitioner's name.• The date of service.• Your mailing address.• The reason why we should change our decision.• A copy of any information that you think supports your appeal. This could include additional documents, records

or information related to your appeal.

Please mail the letter to:Aetna Better Health of West VirginiaAttn: Appeals Department500 Virginia Street, EastSuite 400Charleston, WV 25301


Aetna Better Health of West Virginia will respond to your appeal within 30 calendar days from the day your appeal is received. If it is in your interest, you can ask for a delay in our decision for up to 14 days. If we need to delay our decision for another reason, we will give you written notice within two calendar days.

You can ask for a fast appeal if your appeal is about our decision to not approve or pay for some or all of your health care services, and you need a decision fast because you have not gotten the health care services and you might be badly hurt if you had to wait for a normal appeal decision. We will call you within 24 hours after we get your appeal to let you know that we have received your appeal. We will schedule a meeting with the Committee no later than 48 hours after we get your appeal. For fast appeals, we will give you our decision within 72 hours after receiving your appeal. The timeframe may be extended by up to fourteen (14) calendar days upon your request or if we show that additional information is required and that the delay is in your best interest. If we decide your appeal does not need to be handled quickly, we will respond to your appeal within 30 calendar days from the day your appeal is received.

A Committee will look at your appeal. None of the people on the Appeal Committee will have been involved in our initial decision on a non‑coverage determination or to not authorize or pay for the health services you are appealing. If your appeal involves a medical issue, the Committee will also talk to a health care professional who has the appropriate training and experience in the field of medicine necessary for making the decision on the medical issue. If your appeal is an administrative appeal (one not based on a medical issue), the Appeal Committee will consist of Health Plan senior management. You can send more information for us to review or, we can review the information we already have.

If we change our decision after reviewing your appeal or fast appeal we will approve your request within 72 hours of our decision.

You may have to pay the cost of services, depending on the outcome of the appeal. You can get copies of documents, records and information about the appeal. We will give these documents to you for free.

If you need help with an appeal, you can call Member Services toll‑free at 888‑348‑2922. We can assist you in completing forms. We also can offer auxiliary aids, interpreters, and other services.

If you are not satisfied with the Aetna Better Health of West Virginia's appeal decision, you can file an appeal to the DHHR ‑ Bureau for Medical Services (BMS) but only after you have gone through the Aetna Better Health appeal process. You must request your appeal with DHHR ‑ BMS within120 calendar days of the Aetna Better Health appeal decision letter. Send your request for an appeal to:

Bureau for Medical ServicesOffice of Medicaid Managed Care350 Capitol Street, Room 251Charleston, WV 25301‑3708

The BMS decision will be sent to you in writing.

If you are not happy with the Bureau for Medical Services decision, you can appeal to the West Virginia Insurance Commissioner by sending your appeal to:

The Office of the Insurance CommissionerP.O. Box 50540Charleston, WV 25305‑0540

If you are not satisfied with the decision of the Office of the Insurance Commissioner, you may appeal to Circuit Court. Your appeal must be filed within 30 days after the Insurance Commissioner's order has been mailed.


State Fair HearingsAs a member of Aetna Better Health of West Virginia, you have the right to request a state fair hearing. You can only request a state fair hearing after you have received notice that Aetna Better Health of West Virginia is upholding the decision to reduce, suspend, or stop your benefits. You must complete the Aetna Better Health of West Virginia appeal process before you can ask for a State Fair Hearing. You must request the state fair hearing no later than 120 calendar days from the date of our decision notice. Contact your local Department of Health and Human Resources for the state fair hearing form.

Once you get the form, please mail it back to:

The West Virginia Department of Health and Human ResourcesOne Davis SquareSuite 100 EastCharleston, West Virginia 25301

If you would like your benefits to continue while the hearing is going on, you or your provider must file a request within 10 calendar days of the date on the Notice of Action letter. You may have to pay the cost of services, depending on the outcome. Parties to the state fair hearing can include the State, Aetna Better Health of West Virginia, your representative, or the representative of a deceased member. The State will hear your case and decide within 90 days of your request for a state fair hearing.

Please call Member Services at 1‑888‑348‑2922 if you have questions about requesting a state fair hearing. You can also call the Department of Health and Human Resources at 304‑558‑1700.

After 120 calendar daysIf you did not request a State Fair Hearing within 120 calendar days, you may still be able to appeal Aetna Better Health's appeal decision that you are unhappy with. You can also use this process if the decision is related to a complaint rather than an appeal. You must have gone through Aetna Better Health's grievance process and it must be within one (1) year of the date of the original decision or issue that you did not agree with or were not happy with.

General notesAetna Better Health of West Virginia's Appeal Committee is not able to resolve complaints in a manner or prescribe any actions, which are in conflict with the written policies of Aetna Better Health of West Virginia, federal law or state statutes. However, the Committee may hear such complaints for the purpose of providing input to management.

The Committee shall not hear any complaint that alleges or indicates liability for professional negligence, commonly known as malpractice.

No suit or claims on this contract may be brought unless all requirements of this procedure have been complied with and unless commenced within one (1) year from the date of occurrence.

At any time during the complaint procedure should you seek the advice of legal counsel, you do so at your own expense.

Aetna Better Health of West Virginia will cooperate with the State in the Fair Hearing Process. Aetna Better Health's responsibilities include, but are not limited to, the following requirements: provide any required documentation, participate in required meetings and abide by the State's final decisions.

State and federal regulation require Aetna Better Health of West Virginia to have clearly outlined member grievance procedures, to inform members of those procedures, and to abide by them. If a plan fails to inform a member of complaint and appeal rights or fails to abide by the complaint and appeal procedures, the plan increases its potential risk for liability in this area. This process ensures that you have the right to a fast complaint and appeal process regarding any denial, termination or reduction of services which could place you at risk or which could seriously harm your health or well‑being.

Members may ask for complaint and appeal result totals by calling Member Services at 1‑888‑348‑2922.


Your benefits during the appeal or State Fair Hearing ProcessWhile your appeal or State Fair Hearing is in process, your Aetna Better Health of West Virginia benefits will continue if:• You or your practitioner files the appeal within 10 days of the date on the notice to deny, reduce, change or end

payment for your health care services or before the effective date of the notice.• Your appeal is about our decision to terminate, suspend or reduce a course of treatment that was already

preauthorized.• The services were ordered by an authorized provider or practitioner.• The time frame covered by the preauthorization has not passed.

Your benefits will continue during the appeal or State Fair Hearing Process as long as your Aetna Better Health of West Virginia eligibility is not terminated by BMS.

Aetna Better Health of West Virginia will pay for the services in question when the final result of the appeal to overturn the original decision. We will pay for some or all of the services as determined by the final appeal decision.

If the final result of your appeal is to uphold the original decision to deny, reduce, change or end payment for your services, we may take back the money that was paid for the services while the appeal was in process. In this case, you will be responsible for paying for the services.

Section 8Eligibility and enrollmentEligibilityNo person is eligible to enroll in Aetna Better Health unless approved by the Department of Health and Human Resources (DHHR) and the Bureau for Medical Services (BMS). For eligibility questions or concerns, please call your DHHR case worker.

EnrollmentBMS will give us the name, address, age and sex of each member enrolled in Aetna Better Health. The effective date of your enrollment will be on your Aetna Better Health ID card. BMS determines your continued enrollment in Aetna Better Health based upon your Medicaid eligibility. To stay enrolled in the program, it is important to complete any review forms as soon as you receive them from BMS. Return them to BMS by the date requested.

Changes in enrollmentWhen your family size changes, you move, or get health insurance other than Medicaid, call Aetna Better Health Member Services and your local DHHR office. You can call Member Services at 1‑888‑348‑2922; TTY: 711.

Call Member Services if:• You have a new person in your family• Someone leaves your family home• You move.

If you move from your current address, we may not be able to cover you under the Aetna Better Health program, but we will help you continue to get services until you are disenrolled. Aetna Better Health Member Services will be able to tell you if your new address is in our service area. Contact your local DHHR office if you move.

Adding a newborn babyPlease call the DHHR Change Center at 1‑877‑716‑1212 to report when your baby is born.

Babies born to mothers in the Aetna Better Health of West Virginia program will be enrolled in the program for a minimum of 60 to 90 days. The newborn is enrolled on the first day of the month of their birth. The 60‑day minimum starts from their day of birth. Call the Change Center at 1‑877‑716‑1212 to make sure your baby does not have a problem receiving care.


DisenrollmentYou can ask to stop your membership in the Aetna Better Health of West Virginia program at any time for any reason. Call the Enrollment Broker at 1‑800‑449‑8466 to disenroll or change to a new Managed Care Organization. You may also call Aetna Better Health Member Services and someone will advise how to stop your membership.

You will be disenrolled if you no longer qualify for Medicaid.

TerminationAll rights to benefits, including hospital care, shall end on the date termination takes effect, except as stated above. Your Aetna Better Health coverage will end if:• BMS disenrolls you as a member.• The contract between us and DHHR ends. In such a case, coverage shall end for all Aetna Better Health members

on the date termination takes effect. DHHR will let you know the date of termination, and the process by which you can continue to get care.

Section 9Terms and conditionsCo-paymentsSome services require the member to pay a co‑payment. Co‑payments are based on the member's household income. The charts in Section 4 of this Handbook list the co‑payments the member needs to pay for each service. The co‑payment amount may be different for each Federal Poverty Level (FPL).

If you get a bill or statementYou should not get a bill from or have to pay a network provider for covered benefits or preauthorized services.

If your practitioner or provider didn't receive payment from us on a provided covered benefit or service, he or she is not allowed to bill you for what we didn't pay. This is called balance billing.

Also, you don't have to pay if we don't pay a network practitioner or provider for covered benefits or services. Finally, you are not liable to pay for a provided covered benefit or service in the event that we didn't receive payment from the department.

If you get a bill from a network provider, you should call the health care provider listed on the bill and make sure they have all of your insurance information. If the provider has your insurance information and you were billed, call Member Services at 1‑888‑348‑2922. If you get a bill that you think you should not have gotten, call us at 1‑888‑348‑2922; TTY: 711.

Aetna Better Health is only liable for services that remain our responsibility.

Relationship to contracting partiesAetna Better Health practitioners have a practitioner‑patient relationship with you and are solely responsible for all health care. The relationship between us and practitioners in the Aetna Better Health network is an independent contractor relationship. Aetna Better Health practitioners are not employees or agents of Aetna Better Health. Neither we nor any person who works for us, works for or is an agent of any Aetna Better Health practitioner. Members are not agents and do not represent us. Members are not liable for any acts or omissions by us, our agents or employees. Members are not liable for any acts or omissions of any other person or company with which we have made or will make arrangements for covered care.


Advance directivesFor members 18 years and older, federal law and the Health Care Decisions Act in West Virginia give you the right to decide the medical care you want. You should let your practitioner or other health care provider know what specific health care you want or do not want if you become very sick or have a life threatening illness. You can also let your practitioner or other health care provider know if you want someone else to make medical decisions for you when you are medically or mentally unable to do so. These are called advance directives. Advance directives can include a living will or medical power of attorney. Your practitioner or other health care provider will write down your wishes or make a copy of your written wishes if you already have them. These advance directives will be made a part of your medical records. You may change your mind at any time by putting your change in writing. We will tell you if the law changes within 90 days of the change.

You should tell your practitioner or other health care provider if you have certain moral and/or religious beliefs that would stop you from making advance directives. Your practitioner or other health care provider will write down your objections to making advance directives and will make this a part of your medical records.

If you have questions about advance directives, call Member Services at 1‑888‑348‑2922; TTY: 711.

ChangesAny statement, term, benefit, or condition of coverage and this Handbook may be changed or removed to meet the terms of the agreement between us and the Department of Health and Human Resources (DHHR). DHHR needs to approve any changes. Changes may be made without the member's consent.

Entire agreementYou are covered under our contract with the DHHR who reimburses us for care provided for in the contract. If there is any difference between what is in this Handbook and what is in the contract between us and DHHR, the contract will control. You can call DHHR if you have questions about the contract between us and DHHR.

The following items make up the entire agreement between you and Aetna Better Health:• The Member Handbook, its attachments and amendments.• The Aetna Better Health ID card.• The contract between us and DHHR, its attachments and amendments.

Notice of Insurance Information Practices (abbreviated)The following is a brief notice of our Insurance Information Practices.

Please be aware of the following:• Personal information about the individual proposed for coverage may be collected from persons other than that

individual.• Personal information, as well as other personal or privileged information subsequently collected by us, may be

disclosed to third parties without your authorization in order to better coordinate your care.• You have a right of access and correction with respect to all personal information collected.

If you request, we will provide you with a complete description of our Insurance Information Practices, which includes:• From whom, other than yourself, personal information may be collected.• The types of personal information that may be collected and the types of sources and investigative techniques

that may be used to collect such information.• To whom we will disclose information and the circumstances under which such disclosures may be made without

your prior authorization.• A description of your rights by law to be able to access, correct, amend or delete recorded personal information.

For more information, you may write to Aetna Better Health Member Services at the address in the front of this Handbook.

Medical and other privileged information provided to us is kept confidential.


Coordination of benefitsIf you or a dependent is entitled to any other health care coverage besides Medicaid, you need to tell us, and DHHR.

An example would be if you or your child is covered under health care coverage of some other person, such as a grandparent or natural parent who does not have custody.

If a benefit is covered by us through Aetna Better Health and by another group health care plan (this includes government plans), we will coordinate benefits with such other plan. No more than 100% of the eligible incurred expenses are paid. The benefits provided by us through the Aetna Better Health program shall be secondary to any such other plan. If we are secondary, we will provide and arrange for your needed services before coordinating with the other plan.

When we pay a total amount that is more than the highest amount of payment needed to meet the intent of this section, we shall have the right to get back such payments. We shall only have the right to get back the excess amount. We shall have the right to get this back from:• Any persons to or for or with respect to whom such payments were made• Any other plan

Each member must give us any information needed to apply this section.

Transfer of benefits and paymentsThe covered care you get under your Handbook belongs only to you. You may not transfer your right to get covered care for someone else.

You may not transfer your right to get payment for covered care. Prior payments to anyone, whether or not there has been a transfer of payment, shall not be a waiver of, and shall not restrict, our right to send future payments to you or any other person or center.

Treatment of MinorsAetna Better Health follows the guidance of West Virginia Code §§ 16‑4‑10 “Minors” and 16‑29‑1 “Copies of Healthcare Records to be Furnished to Patients.” Anyone over 16 who has been deemed emancipated in a court of law, or who is over 16 and legally married, will be treated, and have all the privileges, rights and duties of an adult.


Aetna Better Health of West Virginia service area (statewide)Barbour CountyBerkeley CountyBoone CountyBraxton CountyBrooke CountyCabell CountyCalhoun CountyClay CountyDoddridge CountyFayette CountyGilmer CountyGrant CountyGreenbrier CountyHampshire CountyHancock CountyHardy CountyHarrison CountyJackson CountyJefferson County

Kanawha CountyLewis CountyLincoln CountyLogan CountyMarion CountyMarshall CountyMason CountyMcDowell CountyMercer CountyMineral CountyMingo CountyMonongalia CountyMonroe CountyMorgan CountyNicholas CountyOhio CountyPendleton CountyPleasants CountyPocahontas County

Preston CountyPutnam CountyRaleigh CountyRandolph CountyRitchie CountyRoane CountySummers CountyTaylor CountyTucker CountyTyler CountyUpshur CountyWayne CountyWebster CountyWetzel CountyWirt CountyWood CountyWyoming County

Value-add servicesPregnancy - Behaviors Services and Rewards 6 Prenatal appointments Pack ‘n Play1 Post‑partum appointment within 21‑56 days of having your baby $50 gift cardEnroll in Moms and Babies Program Pack ‘n Play or Baby Wrap CarrierComplete the Moms and Babies Program Educational ToyPreventive Dental Program Up to 2 check‑ups during pregnancyWalking programReceive a pedometer and log for tracking your steps $25 gift for completing an 8 week programDentalProvided upon request Dental Hygiene Kit

(pediatric or adult toothbrush, paste, floss)Diabetes*Enroll in diabetic education program and complete A1C testing $25 gift cardEnroll in diabetes care management Free GlucometerGood health practicesYearly well visit ages 12‑18 $25 gift cardTimely behavioral health follow‑up appointment (within 7 days) $25 gift cardHealthy activitiesHealth Related Camps for Children Camp scholarships *available in certain counties


Nondiscrimination Notice

Aetna complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Aetna does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

Aetna:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages

If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card or 1-800-385-4104.

If you believe that Aetna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our Civil Rights Coordinator at:

Address: Attn: Civil Rights Coordinator 4500 East Cotton Center Boulevard Phoenix, AZ 85040 Telephone: 1-888-234-7358 (TTY 711) Email: [email protected]

You can file a grievance in person or by mail or email. If you need help filing a grievance, our Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, and its affiliates.


Help in your languageENGLISH: 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).

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)。

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).

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.

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).

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.

JAPANESE: 注意事項:日本語をお話になる方は、無料で言語サポートのサービスをご利用いただけます。 IDカード裏面の電話番号、または 1-800-385-4104 (TTY: 711)までご連絡ください。

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).

ITALIAN: ATTENZIONE: Nel caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuita. Chiamare il numero sul retro della tessera oppure il numero 1-800-385-4104 (utenti TTY: 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).

WV-17-06-02 www.aetnabetterhealth.com/westvirginia

Documents

Aetna Better Health of West Virginia... Member Services 1‑‑4‑2922 • TTY 711 1Welcome to Aetna Better Health® of West Virginia Your decision to join Aetna Better