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Seeing the doctors you know and trust

The following email was sent on March 3, 2023, to all members of the Retired Teachers Chapter from UFT President Michael Mulgrew and Retired Teachers Chapter Leader Tom Murphy: 

Let's talk... doctors

Making sure you can continue to see the doctors you know and trust is extremely important to us.

The proposed Aetna plan is a Preferred Provider Organization (PPO) plan that is custom-built to give our Medicare-eligible retirees maximum choice when it comes to selecting their health care providers. Aetna has an extensive network of doctors and hospitals both in New York City and nationwide. Both Memorial Sloan Kettering and the Hospital for Special Surgery are in network. You do not need a referral to see a specialist. Because it is a PPO plan, you can see any doctor or hospital even if they are not in Aetna’s network (as long as they accept Medicare and accept payment from Aetna). An out-of-network provider will be reimbursed at the Medicare allowable rate, just like they are today, if they bill Aetna directly.

Continuity of care

About 96% of doctors who take GHI Senior Care are either already in Aetna’s network or accept payment from Aetna. If we move forward with the proposed plan, Aetna will do extensive outreach to the remaining 4% of GHI Senior Care providers who do not have a billing history with Aetna to get even more to come on board between now and Sept. 1.

The proposed plan includes an online tool for you to look up whether or not your current doctor or hospital is in network. If they are not in the network, you can call the Aetna Member Services hotline and the company will reach out to your provider, explain how the new plan works and encourage them to join the network or set up billing with Aetna.

If the plan is approved next week, give Aetna a few weeks to inform doctors. Then proactively making sure all your providers are set up with Aetna will ensure a smooth transition come September.

National and international coverage

Aetna has a network of more than 1.2 million providers and 4,900 hospitals nationwide. The Aetna Medicare Advantage PPO plan is a robust national plan. It comes with you wherever you live or move within the United States, Puerto Rico and other U.S. territories.

When you are traveling within the United States, you can see any doctor that participates in Medicare and is willing to accept the plan or bill Aetna.

The plan will cover urgent and emergency care while you are traveling outside the United States. You will need to pay for the costs up front and then submit paid receipts to Aetna directly for reimbursement. Aetna reimburses the provider at Medicare rates.

Out of network?

Even if your doctor or hospital remains out of network, because this is a PPO plan, any doctor or hospital that accepts Medicare and is willing to bill Aetna will be reimbursed by the company at the Medicare allowable rate. You’ll have the same cost share, whether your provider is in or out of network.

Of course, regardless of your insurance plan, a doctor has the discretion to say they will not see a particular patient.

Provider Pass

What happens if you are taken by surprise at a doctor’s office and your doctor accepts Medicare but refuses to accept the Aetna Medicare Advantage PPO plan? You have a one-time opportunity to use Provider Pass right then and there.

Call Aetna’s special number from your doctor’s office. Aetna will get on the phone with the provider and make a one-time payment of the bill right then so you can keep your appointment for that day. Your call will also prompt Aetna’s member services team to call the provider's office to educate them about how the plan works and how they can join the network or bill Aetna directly. Aetna will then reach out to you and tell you how that conversation went.

If the doctor continues to refuse to bill Aetna directly, Aetna will either help you find another provider or you can continue to see the doctor but you will have to pay the doctor’s bill upfront and then submit the bill to Aetna for reimbursement.