Frequently Asked Questions for
State of Maine Health Plan Members


For any other questions you may have please contact the
State of Maine Employee Health and Benefits Division at
1-800-422-4503 or 207-624-7380
. If you are an Ancillary Group member please contact your benefits office.

Also available to you is Aetna Member Services at: 1-855-850-0039
for Active Employees and Non-Medicare Retiree Members.
And Aetna Member Services at: 1-888-267-2637 for Medicare
Retiree Members.

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Below are Frequently Asked Questions for Active Employees and
Non-Medicare Retiree Members:


To be sure that your Doctor is in Network, go to Aetna DocFind® in the Toolkit for PCPs and Hospitals or call Member Services at 1-855-850-0039.

There are only certain times of the year that you can make changes to your family status. A list of qualifying events can be found at www.maine.gov/deh.

In the plan effective 7/1/13 You will no longer need to get a referral from your Primary Care Physician for specialty care.

You can call Aetna Member Services at: 1-855-850-0039. It will take 7-10 days for your new card to reach you. You can also order your card on Aetna Navigartor AND print a temorpary ID card should you need it for a Doctor appointment prior to the 7-10 days.

There are several good reasons to pick a PCP, they include: having a provider that knows you and your health and you get the best financial benefit picking a PCP in your plan and via your Health Risk Assessment (HRA) Credit.

If you are seeing a PA or NP associated with an In Network provider then the claims will be processed as if you were seeing a Doctor. Sometimes the NP or PA does not have their own Tax ID, and the claims system may not recognize them. This is an easy fix, Aetna will just need to know the name of the participating provider in the office.

Below are Frequently Asked Questions for Medicare Retirees:


For those who reside within Aetna’s plan service area, the plan is an Aetna Medicare Advantage Preferred Provider Organization plan (PPO). It offers benefits beyond Original Medicare and includes programs only available to Aetna members.

For those who reside outside Aetna’s plan service area, the plan is an Aetna Medicare Advantage Preferred Provider Organization plan (PPO) with an Extended Service Area (ESA). It provides benefits beyond Original Medicare and includes programs only available to Aetna members.

The Aetna Medicare PPO Plan has an extended service area. This means that Aetna may extend enrollment in our plan to you even if you live outside the Aetna Medicare network service area.

For the PPO, if you see a medical provider and/or visit a hospital in or out of our nationwide Aetna Medicare network. Services received from out-of-network providers generally require a higher cost share.

The PPO “ESA” plan allows you to see any licensed provider who is eligible to receive payment from Original Medicare and agrees to accept the PPO ESA plan. Most providers will bill Aetna directly. If your provider is not willing to bill Aetna on your behalf you may be required to pay your provider up front and request reimbursement from Aetna.

To confirm if you reside in a county that qualifies as the PPO plan with Extended Service Area, please contact Aetna at 1-888-267-2637 (TDD: 711); 8 a.m. to 6 p.m., 7 days a week.

  • Preventive benefits beyond Original Medicare at no additional cost.
  • Choosing providers in-network provides an additional level of assurance because contracted providers must go through a detailed Aetna credentialing review process.
  • PPO Coverage provided for participating providers outside of the Aetna Medicare network.
  • There is only one benefit level in the PPO ESA plan. You pay the same cost sharing level for covered services even if you receive care from out of network providers.
  • No referrals necessary for covered services. o Free health and wellness programs for you to use.
  • You’re always covered for medical emergencies when traveling anywhere in the world.
  • You have coverage for unlimited inpatient hospital days, unlike Original Medicare.
  • Virtually no claim forms.
  • Access to the National Medical Excellence Program®, a select network of respected doctors and facilities that helps ensure members with a complex illness or injury receive the most appropriate care.
  • Get discounts on vitamins and other health-related products and services.
  • Stay informed with online tools and a 24-hour toll-free health information line.
  • To qualify, you must be enrolled in Medicare Part A and enrolled in Part B, and continue to pay your monthly Part B premium.
  • You must live in the plan service area to be in the Aetna Medicare Advantage PPO plan, otherwise you will be in the Aetna Medicare Advantage PPO-ESA (Extended Service Area) plan
  • You’ll enjoy predictable out-of-pocket cost limits on every plan
  • Services received from a provider that is not eligible to receive payment from Original Medicare will not be covered, except in an urgent or emergency situation.

Yes, you will receive a new Aetna Medicare ID Card. You must present your new Aetna Medicare ID Card to your provider. If your provider is not in our Aetna Medicare network, you need to inform your provider that you are enrolled in the Aetna Medicare PPO Plan or Aetna Medicare PPO Plan with an Extended Service Area (ESA) before obtaining a service.

If you are in the Aetna Medicare PPO plan and your doctors participate in our Aetna Medicare network, you can continue to see them like you always have and will continue to pay the lower in-network cost sharing amount. If you see a provider that does not participate in our Aetna Medicare network, the provider must be licensed, willing to accept the Aetna Medicare PPO plan and be eligible to receive payment from Medicare. You will generally pay a higher cost share when receiving services from out-of-network providers.

If you are in the Aetna Medicare PPO plan with an Extended Service Area (ESA), you are free to see any provider who is licensed, willing to accept the Aetna Medicare PPO plan and is eligible to receive payment from Medicare.

Access the most up-to-date information on participating providers by visiting DocFind®, our online provider directory.

Step 1: Go to www.aetnastateofmaine.com and click on DocFind in the ToolKit section.

Step 2: Complete the geographic information, provider category and provider type you are looking for.

Step 3: Under Plan, scroll down the list to Aetna Medicare. If you do not have access to a computer, call a Member Services representative dedicated to finding a participating provider at 1-888-267-2637 (TDD: 711); 8:00 a.m. to 6:00 p.m., 7 days a week.

If your provider is not contracted with Aetna but is eligible to receive Medicare payment, you can continue to use this provider by using your out-of-network benefits and if your provider agrees to accept your Aetna Medicare PPO plan.

If your provider is not contracted with Aetna, your provider can learn more about this plan by logging on to our provider secure website via NaviNet, available through www.aetna.com. Your provider may also call our dedicated Provider Services department at 1-800-624-0756.

Yes, we have highly successful programs that are designed to help you manage your current conditions and keep you healthy. An Aetna Nurse Case Manager or Disease Management Nurse may reach out to you after you enroll in the plan.

Your doctor can learn more about this plan by logging on to our provider secure website via NaviNet available through www.aetna.com. Your doctor may also call our dedicated Provider Services department at 1-800-624-0756.

Even though you will not be using your red, white and blue Medicare card when you receive medical services, you remain a Medicare beneficiary and should keep it in a secure, safe place where it will not be lost, stolen or damaged/destroyed. Many retirees put it into a safe deposit box at a back or a safe box in their home.

Call a Member Services representative at 1-888-267-2637 (TDD: 711); 8 a.m. to 6 p.m., 7 days a week


 
Trying to find out if your doctor's in our network?
Go to DocFind® to do a quick search.



 

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