Rights & Resources

Know your health insurance rights

As a Texas Health Aetna member, you are entitled to information that helps you:

• Make the most of your benefits
• Coordinate your care
• Understand how we make coverage and claims decisions
• Appeal a denied claim
• Get care

Get to know your rights concerning your plan and your care and why we may not pay for certain services .

You want to protect your benefits. We understand. And we know you may not always agree with our decisions. Find out how to:

• File a complaint, grievance or appeal about Texas Health Aetna, your plan, or a health care service, provider or professional
• Appeal the decision when we don't pay for all or part of a claim

Use our resources to make decisions about your doctors, treatments and health plans to get quality care.

Life brings changes that affect your health insurance. Maybe you've gotten married or had a child. Or you're leaving your job. Learn about your options for changing your health coverage.

Your Rights

As a Texas Health Aetna member, you have the right to certain information and services from us.

And from the health care professionals who care for you. This includes the right to appeal a denied claim.

You also have certain responsibilities, such as learning about your health benefits plan.

Know your rights and responsibilities. Doing so can help you understand and use your health care benefits.

View my rights and responsibilities

• I am a Texas Health Aetna Commercial HMO or PPO member

Know your plan details

We give you important details about how your health benefits plan works. These are called disclosures.

Claims & Coverage

How we decide what services to cover

Our goal is to help you get the proper care for your condition. However, we do not pay for every type of care a person wants.

We make decisions about what to pay for based on the member’s health plan and generally accepted guidelines and policies.

• We do not reward our employees or anyone else for denying a claim. In fact, we make known the risks of not providing proper care.
• We make coverage decisions on a case-by-case basis consistent with applicable policies.
• We review many of the services used by patients. These include tests, treatments, surgeries and hospital stays. We use nationally recognized guidelines to decide whether a service is appropriate and, therefore, covered. If we do not consider the service to be needed, we do not pay for it.

When we do not pay for a service it is called a denied claim. If your claim is denied, we will send you a letter to let you know. If you don't agree, you can file an appeal. Once there are no appeals left, independent doctors may review your denied claim. This is called an external review.

Aetna and its affiliates provide certain management services for Texas Health Aetna.

We comply with Federal laws

Texas Health Aetna does not discriminate in providing access to health care services on the basis of race, disability, religion, sex, sexual orientation, health, ethnicity, creed, age or national origin. Federal law mandates that Texas Health Aetna comply with Title VI of the Civil Rights Act of 1964, the Age Discrimination Act of 1975, the Americans with Disabilities Act, other laws applicable to recipients of federal funds, and all other applicable laws and rules.

We review new technologies

To decide if our plans' benefits should cover new medical technologies, we:

• Study their safety and effectiveness based on the research
• Talk to experts
• Consider guidelines from medical and government groups, including the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS)
• Determine whether new tests, procedures, and treatments are experimental or investigational

Texas Health Aetna’s policies about specific medical technologies are described in clinical policy bulletins.

We also review existing tests, procedures, and treatments to see if they can be used in new ways and to determine the appropriate policies for paying claims.

How Texas Health Aetna pays claims for out-of-network benefits

We negotiate rates with doctors, dentists and other health care providers to help you save money. We refer to these providers as being "in our network." Some of our benefit plans pay for services from providers who are not in our network. Read how we pay for out-of-network care and how we calculate those payments. Always check the language of your benefit plan to determine which method Texas Health Aetna uses to pay your out-of-network benefits.

External Review

Affordable Care Act

The Patient Protection and Affordable Care Act (PPACA) was enacted on March 23, 2010.  The Department of the Treasury, Department of Labor and the Department of Health and Human Services issued interim final regulations implementing the requirements regarding internal claims and appeals and external review processes for group health plans and health insurance coverage in the group and individual markets.

In compliance with the Affordable Care Act and modeled after the Uniform Health Carrier External Review Model Act (NAIC Uniform Model Act), covered persons must have the opportunity for an independent review of adverse determinations or final adverse determinations based on medical judgment or a determination that a recommended or requested health care service or treatment is experimental or investigational or for rescission of coverage. Your plan type and the state of your contract or residence will determine whether your coverage denial is subject to state or federal standard regulations.

All non-grandfathered plans (self-funded, insured, group & individual) are subject to some form of external review process. Your plan documents will provide a description of the applicable external review process.  You will be provided with the applicable external review rights along with a description of how to pursue an external review in the adverse or final adverse determination letter as you exhaust the internal appeal process.

States that have an external review process that meets certain minimum consumer protections set forth under federal requirements will be allowed to apply their state external review process. Health insurers must comply with the state external review process in those states.  If your plan is subject to a state mandated process, a description of that process will be provided in your plan documents.

Claims Denials

How to appeal a denied claim

If we deny a claim and you do not agree, you can ask for a review. This is called an appeal. Log in to your secure member website for more information or call us at the number on your member ID card.

You may appeal on your own. You also may authorize someone to appeal for you. This is called an authorized representative.

How long do I have to ask for an appeal?

You have 180 days from when you get the notice of the denied claim, unless your plan brochure (or Summary Plan Description) gives you a longer period of time.

What should the request include?

• The group name (usually your employer or organization that sponsors your plan)
• Your name
• Your member ID number (found on your  medical ID card)
• Any comments, documents, records and other information you would like us to consider. (If there are documents you need for your claim, call the Member Services phone number listed on your member ID card. We will send them to you free of charge.)

How long will it be before Texas Health Aetna makes a decision?

How soon we respond may vary. It depends on state law, whether your appeal is urgent or your plan offers one or two levels of appeal.

Plans that provide for one appeal

• If we had to approve your claim before you got care, we will decide within 30 days of getting your appeal.
• For other claims, we’ll decide within 60 days.

Plans that provide for two appeals

• If we had to approve your claim before you got care, we will decide within 15 days of getting your appeal.
• For other claims, we’ll decide within 30 days.
• In either case, if you do not agree with our decision, you can ask for a second review. You have 60 days from the date that you get the appeal decision letter to let us know. You can call Member Services at the phone number listed on your member ID card, or write to us.

Urgent care claims

We make decisions for urgent care claims more quickly. If your doctor feels that a delay will put your health, your life or your recovery at serious risk or cause you severe pain, that’s an urgent care claim. You or your doctor may ask for an "expedited" appeal. Call the toll-free number on your Member ID card or the number on the claim denial letter.

• If your plan has one level of appeal, we’ll tell you our decision no later than 72 hours after we get your request for review.
• If your plan has two levels of appeal, we’ll tell you our decision no later than 36 hours after we get your request for review.

What is an external review?

What if your claim is still denied after your appeal(s)? You may be able to have a third party (independent party) review your denied claim. This is called an external review.

The Affordable Care Act (ACA) created new rules for health plans. Now health plans that are subject to the law must include an external review process. Learn more about the Texas Health Aetna External Review Program and if your claim denial is eligible for external review.

Options for Changing Health Coverage

Life Changes. So Can Your Coverage

If you have health benefits through your employer, you can change them during "open enrollment." It's typically in the fall. It's your chance to choose a new health plan, pick new benefits or cancel your current plan.

The only other times you can change your health benefits is when you:

• Get married
• Get a divorce or legal separation
• Give birth or adopt a child
• Lose your health coverage because your spouse or domestic partner lost his or her job
• Lose your health coverage because your spouse or domestic partner died

Check with your employer to learn more.

When job-related changes happen

Losing a job or changing jobs usually means giving up the health insurance plan you have through work. Here are some options for getting new health coverage:

• Find out if you can stay on your employer's health plan for a period of time through the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).
• Join a government program, such as Medicaid.
• Understand your rights. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) makes it easier for people to change jobs without losing health coverage. 

Graduating college?

This may be the first time you're thinking about health benefits. To get covered consider these options:

• Join or stay on your parent's health plan. Contact the employer's Human Resources department for more information.
• Getting coverage through a new employer.

COBRA

If your employer is subject to federal COBRA, you may be eligible to continue your group health plan coverage on a temporary basis. This coverage, however, is only available when coverage is lost due to specific events. For more information, please contact your employer.

Conversion

Conversion is medical coverage for people who are no longer eligible for the group’s medical coverage due to such circumstances as:

• Loss of employment
• Expiration of COBRA/continuation or
• Loss of eligibility as a dependent.

There can be no lapse in coverage from the termination date of the employer group plan to the effective date of the individual conversion plan. Individual conversion plans do not require medical underwriting. Individual conversion benefits will differ from the group benefits and will vary depending on your state of residence.

There is a limited time to apply for the conversion policy. Members must apply and pay the first premium within 31 days of termination of group coverage. To determine if your plan provides a conversion option and what benefits are available, please contact the traditional medical conversion unit at (866) 901-2922 or the HMO medical conversion unit at (866) 565-1235.

Pennsylvania continuation

Full-time students who are eligible for health insurance coverage under their parents' health plan, who are members of the Guard or Reserve, and who meet the eligibility conditions, are eligible to be covered under their parents’ health insurance coverage for additional time after they become a full-time student in an accredited institution of higher learning. Their coverage will extend for the shorter period equal to the duration of the dependent's service or until they are no longer full-time students. For more information, please call the number that is printed on your ID card.