Things you need to know about Aetna Individual Health Plans
To qualify for an Aetna Advantage Plan, you must be:
- Under age 64 3/4 (If applying as a couple, both you and your spouse must be under 64 3/4.) n Under age 19 for dependent children
- Between 19 and 23 for unmarried dependent children with proof of full-time student status
- Legal residents in a state with products offered by the Aetna Advantage Plans n Legal U.S. residents for at least 6 continuous months.
Your premium payments
Your premium payments are guaranteed not to increase for 12 months from your effective date once you’ve been accepted for coverage. After that, your premiums may change. Final rates are subject to underwriting review.
Your coverage remains in effect as long as you pay the required premium charges on time, and as long as you maintain membership eligibility. Coverage will be terminated if you become ineligible due to any of the following circumstances:
- Non-payment of premiums
- Becoming a resident of a state or location in which Aetna Advantage plans are not available.
- Obtaining duplicate coverage
- For other reasons permissible by law
Medical underwriting requirements
The Aetna Advantage Plans are not guaranteed issue plans and require medical underwriting. Some individuals may be federally eligible under the Health Insurance Portability Accountability Act (HIPAA) for a special guaranteed issue plan under Florida laws and regulations.
All applicants, enrolling spouses and dependents are subject to medical underwriting to determine eligibility and appropriate premium rate level.
We offer various premium rate levels based on the known and predicted medical risk factors of each applicant.
Levels of coverage and enrollment
- You may be enrolled in your selected plan at the standard premium charge.
- You may be enrolled in your selected plan at a higher rate, based on medical findings.
- You may be declined coverage based on significant medical risk factors.
If you are currently covered by another carrier, you must agree to discontinue the other coverage before or on the effective date of the Aetna Advantage Plan. Do not cancel your current health coverage until you are notified that you have been accepted for coverage.
During the first 12 months following your effective date of coverage, no coverage will be provided for the treatment of a pre-existing condition unless you have creditable prior coverage.
A pre-existing condition is an illness or injury for which medical advice or treatment was recommended or received within 6 months preceding the effective date of coverage.
All You Need to Know About easy-Pay
Simple Automatic Payments via Electronic Funds Transfer (EFT)
registration: Complete the payment section of the Aetna Advantage Plans application. Select the EFT option to approve the automatic withdrawal of your initial premium and all subsequent premium payments.
Invoices: You will not receive a paper invoice when you are enrolled in EFT. Payments will appear on your bank statement as “Aetna Autodebit Coverage.”
Terminating: To terminate EFT, you will need to provide Aetna with 10 days written notice prior to the date your next EFT payment will be deducted. Without this written notice, your bank account may be debited for the next month’s premium. You will then need to contact Aetna to have funds placed back in the checking account.
refunds: To process an EFT refund (placing money back in member’s checking account), Aetna will require at least 5 days after the withdrawal was made to ensure valid payment.
rejected transactions: If the EFT payment rejects for any reason, Aetna will automatically terminate the EFT and send you a letter saying you will receive paper invoices. Processing time to reinstate EFT will be 30–60 days. If an EFT payment is rejected, you will need to pay that payment by paper check or credit card.
Timing: Payments for Cycle 1 accounts (1st of the month effective date) will be taken from your bank account between the 3rd and the 10th of the month the premium is due. Payments for Cycle 2 accounts (15th of the month effective date) will be taken from your bank account between the 18th and 23rd of the month the premium is due.
These medical plans do not cover all health care expenses and include exclusions and limitations. You should refer to your plan documents to determine which health care services are covered and to what extent.
The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s). Services and supplies that are generally not covered include, but are not limited to:
All medical and hospital services not specifically covered in, or which are limited or excluded by your plan documents, including costs of services before coverage begins and after coverage terminates
- Cosmetic surgery
- Custodial care
- Donor egg retrieval
- Weight control services including surgical procedures for the treatment of obesity, medical treatment, and weight control/loss programs
- Experimental and investigational procedures, (except for coverage for medically necessary routine patient care costs for Members participating in a cancer clinical trial)
- Charges in connection with pregnancy care other than for pregnancy complications
- Immunizations for travel or work n Implantable drugs and certain injectable drugs including injectable infertility drugs n Infertility services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services unless specifically listed as covered in your plan documents
- Medical expenses for a pre-existing condition are not covered for the first 12 months after the member’s effective date. Look back period for determining a pre-existing condition (conditions for which diagnosis, care or treatment was recommended or received) is 6 months prior to the effective date of coverage. If the applicant had prior creditable coverage within 63 days immediately before the signature on the application, then the pre-existing conditions exclusion of the plan will be waived.
- Nonmedically necessary services or supplies
- Over-the-counter medications and supplies
- Radial keratotomy or related procedures
- Reversal of sterilization
- Services for the treatment of sexual dysfunction or inadequacies including therapy, supplies or counseling
- Special or private duty nursing
- Therapy or rehabilitation other than those listed as covered in the plan documents
- Mental Health services for Managed Choice Open Access and POS Open Access plans not covered.
- Chemical dependency and substance abuse not covered.
Listed below are some of the charges and services for which these dental plans do not provide coverage. For a complete list of exclusions and limitations, refer to plan documents.
- Dental Services or supplies that are primarily used to alter, improve or enhance appearance. Negotiated rates for cosmetic procedures available when a participating dentist is accessed.
- Experimental services, supplies or procedures
- Treatment of any jaw joint disorder, such as temporomandibular joint disorder n Replacement of lost or stolen appliances and certain damaged appliances n Services that Aetna defines as not necessary for the diagnosis, care or treatment of a condition involved
- All other limitations and exclusions in your plan documents
10-day right to review
Do not cancel your current coverage until you are notified that you have been accepted for coverage. We’ll review your application to determine if you meet underwriting requirements. If you’re denied, you’ll be notified by mail. If you’re approved, you’ll be sent an Aetna Advantage Plan contract and ID card.
If, after reviewing the contract, you find that you’re not satisfied for any reason, simply return the contract to us within 10 days. We will refund any premium you’ve paid (including any contract fees or other charges) less the cost of any services paid on behalf of you or any covered dependent.
This material is for information only and is not an offer or invitation to contract. Plan features and availability may vary by location. Plans may be subject to medical underwriting or other restrictions. Rates and benefits may vary by location. Health benefits, health insurance and dental insurance plans contain exclusions and limitations. Investment services are independently offered through JPMorgan Institutional Investors, Inc., a subsidiary of JPMorgan Chase Bank. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Not all health services are covered. See health insurance plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features are subject to change. Aetna receives rebates from drug makers that may be taken into account in determining Aetna’s Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a licensed pharmacy subsidiary of Aetna Inc., that operates through mail order. Material subject to change.