January 1 – December 31, 2021
      Evidence of Coverage:
      Your Medicare Health Benefits and Services as a Member of Aetna 
      Medicare Eagle Plan (PPO)
      This booklet gives you the details about your Medicare health care coverage from January 1 – 
      December 31, 2021. It explains how to get coverage for the health care services you need. This 
      is an important legal document. Please keep it in a safe place.
      This plan, Aetna Medicare Eagle Plan (PPO), is offered by AETNA LIFE INSURANCE COMPANY. 
      (When this Evidence of Coverage says “we,” “us,” or “our,” it means AETNA LIFE INSURANCE 
      COMPANY. When it says “plan” or “our plan,” it means Aetna Medicare Eagle Plan (PPO).)
      Please contact our Member Services number at 1-800-282-5366 for additional information. 
      (TTY users should call 711.) Hours of operation are 8 am to 8 pm, 7 days a week.
      This document may be made available in other formats such as braille, large print or other 
      alternate formats.
      Benefits, premium, deductible, and/or copayments/coinsurance may change on January 1, 
      2022.
      The provider network may change at any time. You will receive notice when necessary.
                     Y0001_H5521_241_PA03_EOC21_C
                          OMB Approval 0938-1051 (Expires: December 31, 2021)
              2021 Evidence of Coverage for Aetna Medicare Eagle Plan (PPO)                                       2
              Table of Contents
                                                  2021 Evidence of Coverage
                                                       Table of Contents
              This list of chapters and page numbers is your starting point. For more help in finding 
              information you need, go to the first page of a chapter. You will find a detailed list of 
              topics at the beginning of each chapter.
              Chapter 1.      Getting started as a member .........................................................................4
                              Explains what it means to be in a Medicare health plan and how to use this 
                              booklet. Tells about materials we will send you, your plan premium, your plan 
                              membership card, and keeping your membership record up to date.
              Chapter 2.      Important phone numbers and resources .................................................13
                              Tells you how to get in touch with our plan (Aetna Medicare Eagle Plan (PPO)) 
                              and with other organizations including Medicare, the State Health Insurance 
                              Assistance Program (SHIP), the Quality Improvement Organization, Social 
                              Security, Medicaid (the state health insurance program for people with low 
                              incomes), and the Railroad Retirement Board.
              Chapter 3.      Using the plan’s coverage for your medical services ................................24
                              Explains important things you need to know about getting your medical care 
                              as a member of our plan. Topics include using the providers in the plan’s 
                              network and how to get care when you have an emergency.
              Chapter 4.      Medical Benefits Chart (what is covered and what you pay) ...................39
                              Gives the details about which types of medical care are covered and not 
                              covered for you as a member of our plan. Explains how much you will pay as 
                              your share of the cost for your covered medical care.
              Chapter 5.      Asking us to pay our share of a bill you have received for covered 
                              medical services ...........................................................................................100
                              Explains when and how to send a bill to us when you want to ask us to pay you 
                              back for our share of the cost for your covered services.
              Chapter 6.      Your rights and responsibilities .................................................................106
                              Explains the rights and responsibilities you have as a member of our plan. Tells 
                              what you can do if you think your rights are not being respected.
              2021 Evidence of Coverage for Aetna Medicare Eagle Plan (PPO)                                       3
              Table of Contents
              Chapter 7.      What to do if you have a problem or complaint  
                              (coverage decisions, appeals, complaints) ...............................................122
                              Tells you step-by-step what to do if you are having problems or concerns as a 
                              member of our plan.
                              ·  Explains how to ask for coverage decisions and make appeals if you are 
                                 having trouble getting the medical care you think is covered by 
                                                                                                       our plan. 
                                 This includes asking us to keep covering hospital care and certain types of 
                                 medical services if you think your coverage is ending too soon.
                              ·  Explains how to make complaints about quality of care, waiting times, 
                                 customer service, and other concerns.
              Chapter 8. Ending your membership in the plan ............................................................162
                              Explains when and how you can end your membership in the plan. Explains 
                              situations in which our plan is required to end your membership.
              Chapter 9. Legal notices .....................................................................................................170
                              Includes notices about governing law and about nondiscrimination.
              Chapter 10. Definitions of important words ...................................................................176
                              Explains key terms used in this booklet.
                CHAPTER 1
        Getting started as a member