Health Care Professionals
 
Home
Resource Center
Forms and Documents Communications Drugs & Prescriptions Health Coverage Business Initiatives
Aetna
Shortcuts
Aetna Aetna
Health Coverage Information

Guidelines for Determining Coverage | Clinical Policy Bulletins | Medicare | Payment Policy | Dispute Process

Please select your segment


To view all available Aetna Medicare Advantage plans and benefit information by zip code, please visit aetnamedicare.com

Medical - Aetna Medicare OpenSM Plan (PFFS)

Aetna Medicare OpenSM Plan
This Medicare Advantage Private Fee-For-Service (PFFS) plan provides all of the benefits covered under Original Medicare and more, such as unlimited hospitalization and full coverage of certain preventive services. Most PFFS plans include prescription drug coverage. Providers that are "deemed" as participating in the Aetna Medicare Open Plan are paid Medicare-allowable rates for covered services rendered to Aetna Medicare Open Plan members, as more fully described in the Aetna Medicare Open Plan Reimbursement Grid. We offer the Aetna Medicare Open Plan to employer groups for their retirees in all fifty states and the District of Columbia, and for individuals in certain markets.

Private Fee-for-Service Overview
A private fee-for-service plan is a Medicare Advantage (MA) product established by the Balanced Budget Act of 1997, which offers eligible Medicare beneficiaries the opportunity to receive benefits that are covered under Original Medicare, as well as the flexibility to receive benefits beyond Original Medicare. It also affords PFFS members the opportunity to receive covered services from any provider that is licensed and eligible to receive Medicare payment and meets and accepts the PFFS plan's Terms and Conditions of Payment Indicates Adobe Reader File Format (10 pages). (referred to as a "Deemed Provider")

PFFS plans are offered through private insurance companies to eligible Medicare beneficiaries within specific geographical service areas approved by the Centers for Medicare and Medicaid Services. Most regulations applicable to the MA program apply to PFFS plans, including enrollment/disenrollment criteria, claims processing, and quality initiatives relating to the MA program.

Note: Please see supporting documents under “Related Documents.”

back to top

Advantages to Providers in Accepting Aetna's Terms and Conditions and Participating in the Aetna Medicare Open Plan as a Deemed Provider
  • No contracts required - as more fully described in the Terms and Conditions of Payment Indicates Adobe Reader File Format (10 pages), licensed providers that are eligible to receive payment under Original Medicare, agree to care for Aetna Medicare Open Plan members, and meet and accept the Plan's Terms and Conditions of Payment Indicates Adobe Reader File Format (10 pages) are considered "participating" in the Aetna Medicare Open Plan.
  • Ease of administration - no precertification or referrals required.
  • Simplified billing - one bill, one remittance. We pay claims directly to providers, in contrast to Original Medicare, which requires that providers wait for intermediaries, carriers and supplemental plans to administer their claims.
  • Lower out-of-pocket member expenses compared to Original Medicare.
  • More covered benefits offered under Aetna Medicare Open Plan than under Original Medicare; therefore, Medicare beneficiaries may determine that the Aetna Medicare Open Plan offers a greater value in comparison to Original Medicare.
  • Increased emphasis on disease and case management versus concurrent review.
  • As more fully described in the Aetna Medicare Open Plan Reimbursement Grid (Updated 11/14/08) Indicates Adobe Reader File Format (13 pages), Medicare-allowable rates paid for covered services rendered by providers participating in the Aetna Medicare Open Plan.
back to top

PFFS Plan Exclusions
Services and Supplies Not Covered
The following is a partial list of services and supplies that are generally not covered under the Aetna Medicare Open Plan. Member PFFS plan documents include a complete list and may also contain exceptions to this list, based on plan design and rider(s) purchased by the employer.
  • Any service not covered by Original Medicare, unless otherwise noted in the Evidence of Coverage (EOC).
  • Cosmetic surgery, including breast reduction.
  • Custodial care.
  • Dental care and dental X-rays.
  • Experimental and investigational procedures.
  • Orthotics except as covered by Medicare
  • Long-term rehabilitation therapy.
  • Services for the treatment of sexual dysfunction or inadequacies including therapy, supplies or counseling.
  • Treatment of behavioral disorders.
back to top

Initial Organization Coverage Determinations
If you have a question about whether the Aetna Medicare Open Plan will pay for a service, including inpatient hospital services, you (members or providers) have the right to request a written advance coverage determination to confirm whether the service requested will be covered. Initial organization coverage determinations for medical services should be requested through the Aetna Patient Management Department. Coverage Determinations related to Medicare prescription drugs being offered under a PFFS plan should be requested through the Aetna Pharmacy Management Precertification Department. You may call the phone number indicated on the member's ID card to obtain a written advance coverage determination.

back to top

Aetna Practitioner/Provider Appeal Process
Aetna will reimburse all Deemed Providers based upon the Medicare-allowable fee schedule, as more fully described in the Aetna Medicare Open Plan Reimbursement Grid. If a Deemed Provider feels that the payment received from the PFFS plan, including the member cost sharing amount, is not equal to the Medicare allowable amount, as described in the Aetna Medicare Open Plan Reimbursement Grid, then the Provider may file an appeal with Aetna for reconsideration regarding the payment amount received.

Additonal Information
More online resources are available on Aetna's secure website for physicians, hospitals and health care professionals. Once logged in, choose “Doing Business with Aetna,” then “Aetna Benefit Products,” followed by “Aetna Medicare.”

Find Member information on www.aetnamedicare.com

Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. The Aetna companies that offer, underwrite, or administer benefits coverage include Aetna Life Insurance Company.

back to top

email this page   
medium small large
Aetna
Aetna