Plan benefits & forms

Call us with your caregiver or another person on the line to give them permission to speak with us (just one time, while on that call). Or you can mail us a completed Protected Health Information (PHI) form to give them permission on a regular basis.

PHI form - English (PDF) | Español (PDF)

You can choose someone to do all of the above. This person is your appointed representative. An appointment is good for one year from the date that you and your representative sign an Appointment of Representative form. 

Fill out the form below and mail it to us. Any time your representative makes a request for you, they should send us a signed copy. You'll leave Aetna Medicare and go to the Center for Medicare & Medicaid Services (CMS) website if you link to the form. 

Appointment of Representative CMS Form - English (PDF) | Español (PDF)

We want to be your first stop when you have a concern about your coverage or care. Call us at the number on your member ID card, or learn more here.

See how to get started

Find these documents online on your secure member website, sometimes you may need a printed version.

View, download, or request a printed Annual Notice of Change (ANOC) or Evidence of Coverage (EOC)

Request a printed Provider Directory  - State and Local Government retirees call ${groupPhoneNumberSHBP} ${tty} and Education retirees ${groupPhoneNumberSHBP} ${tty}, ${memberhours}. 

Medicare Helpline & Website - Get general or claims-specific Medicare information, request documents in alternate formats and make changes to your Medicare coverage. Call 1-800-MEDICARE (1-800-633-4227) or TTY: 1-877-486-2048, 7 days a week, 24 hours a day. If you need help in a language other than English or Spanish, say “Agent” to talk to a customer service representative. Or visit the Medicare website. 

Social Security Administration - For questions about Medicare eligibility, Social Security retirement benefits or help paying for prescription drugs. Call 1-800-772-1213 or TTY: 1-800-325-0778, Monday to Friday, 8 AM to 7 PM or visit the Social Security website.

Most health care professionals and organizations that provide Medicare services are honest. Unfortunately, there may be some who are not. If you ever suspect fraud, please contact Member Services at the number on the back of your ID card, or call Medicare toll-free at 1-800-MEDICARE (1-800-633-4227) or TTY: 1-877-486-2048, 7 days a week, 24 hours a day.

Let us know 

If you’re moving or getting a new phone number you can update your information by: 
 

• Visiting the Division of Pensions and Benefits website, where you can log in to access your Member Benefits Online System (MBOS) account. 
• Calling the Division of Pensions and Benefits at 1-609-292-7524 ${tty}, Monday to Friday, 7 AM to 4:30 PM ET (except on State holidays).

We help you get medically necessary health care services in the most cost-effective way under your health plan. And we work with you and doctors to evaluate services for medical appropriateness, timeliness and cost. 

Specifically, we: 
 

• Base our decisions on appropriateness of care, service and plan coverage 

• Use nationally recognized guidelines and resources to make changes 

• Don’t pay or reward providers, employees or others for denying coverage or care 

• Focus on reviewing the risks of members who aren’t fully using certain services
  

Doctors and health care companies continuously develop new technologies. This can include anything from a new procedure to a new way to use a device.

When we learn about a new technology, we:
 

• Carefully review the latest information and ask experts for their opinions

• Compare the information with well-known standards

• Base all of our decisions on making sure you have the right care and services
  

Your coverage for out-of-network providers depends on the type of plan you have.  

If you’re enrolled in an Aetna Medicare^SM  (PPO) plan with Extended Service Area (ESA)

A PPO plan with an extended service area (ESA) gives you the flexibility to see any provider, in or out of network, at the same cost, according to the costs listed on your plan benefits summary. They just have to be licensed, eligible to receive Medicare payments and willing to accept your plan. 

With a PPO plan with ESA, you have the option to choose a primary care physician. But when we know who your doctor is, we can better support your care. 

a. For more information:

1. State Health Benefits Program retirees click here
2. School Health Employee Benefits Program retirees click here

If you’re enrolled in an Aetna Medicare^SM HMO plan 

An HMO plan requires you to stay within your network of providers to receive coverage except in urgent or emergency situations. You must also select a primary care provider and receive a referral in order to see a specialist.

See if your chosen provider or facility is part of the Aetna network

Please call us or see your Evidence of Coverage for more information, including the cost share for out‐of‐network services.

The Centers for Medicare & Medicaid Services periodically issues National Coverage Determinations. They issue these when a service’s or drug’s coverage rules change. 

View a list of coverage determinations