Business Profile

Insurance Companies

Aetna Inc.

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Complaints

This profile includes complaints for Aetna Inc.'s headquarters and its corporate-owned locations. To view all corporate locations, see

Customer Complaints Summary

1,334 total complaints in the last 3 years.
467 complaints closed in the last 12 months.

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The complaint text that is displayed might not represent all complaints filed with BBB. Some consumers may elect to not publish the details of their complaints, some complaints may not meet BBB's standards for publication, or BBB may display a portion of complaints when a high volume is received for a particular business.

Initial Complaint
Date:02/24/2025
Type:Billing Issues
Status:
ResolvedMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
My Aetna Supplemental ******** Indemnity policy pays a ******** stay benefit of $200 per day.
I am a cancer patient under the care of a transplant team at ************ *******. On 7/24/25, I went to my local ER at ************. I was admitted & spent the night. The following day, my transplant team requested I be transferred to the ******* ******** location under their care. I was transported by ambulance from ************ **** to ************ ******* where I spent 3 days (7/25 – 7/28/24).
A claim for dates 7/24 – 7/28/24 were submitted to Aetna 9/25/24. On 12/12/24, the ****’s were uploaded to Aetna’s system in support of claim# ************ for dates of service 7/24 – 7/28/24.
On 12/26/24, Aetna made payment for ************ **** 7/24 – 7/25/24 admission benefit and the 1 day stay under a new claim# ************ but paid nothing for the 7/25 – 7/28/24 hospitalization at ************ *******. On 12/27/24, I contacted Aetna regarding the missing payment & was advised I had to put in a new separate claim for 7/25 - 7/28/24 ************ ******* ******** stay to be considered. On 12/27/24, I created a new claim (claim# ***********) and uploaded the same **** that had previously been uploaded for the 7/25 – 7/28/24 ******** stay. On 1/30/24, I received a letter indicating they were denying the claim as a duplicate. Clearly, Aetna is not doing their job or even looking at the **** because it clearly indicates the dates of service for my hospitalization of 7/25 – 7/28/24 & their EOB statement of 12/26/24 clearly has the dates they made payment for which do not include the 3 day ******** stay of 7/25 – 7/28/24.
I am battling cancer and do not need the added stress of baby-sitting Aetna to make sure they are correctly processing my claims. They are obviously not doing their job & they need to actually read & process what is being sent to them.
Business Response
Date: 02/26/2025
**** *** ******* **********

Please see our
response to complaint #******** for ******* ******* that was received by us on February 24,
2025. Our Executive
Resolution Team researched your concerns, and I would like to share the results
of the review with you.

Upon receipt of your request, we immediately
reached out internally to have *** *******’s concerns reviewed. We have
confirmed that the claim ************ for the dates of service July 25, 2024,
through July 28, 2024, has been processed with a payment of $600.00. The member
is enrolled in direct deposit, therefor the payment will be sent to her bank
account by the end of day on February 26, 2025.

We take customer complaints very seriously and
appreciate you taking the time to contact us and giving us the opportunity to address *** *******’s concerns. If there are any additional
questions regarding this particular matter, please contact the Executive
Resolution Team at *******************************.

Sincerely,

Marshell H.
Analyst, Executive Resolution
Executive
Resolution Team
Customer Answer
Date: 02/26/2025

Better Business Bureau:

I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me.
It's just a shame that they couldn't have appropriately processed the claim to begin with!

Sincerely,

******* *******
Initial Complaint
Date:02/21/2025
Type:Product Issues
Status:
ResolvedMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
Aetna insurance has a fitness reimbursement program in which they stated in their brochure that if you purchased a kayak you would be reimbursed. They originally denied my claim and I filed an appeal which was also denied. In their response to my appeal they admitted in writing that they were wrong but still refused to pay. My Aetna member ID # ************. The claim denial is *********.
Business Response
Date: 02/24/2025
Please see our response to complaint # ******** for *** ***** **** that was received by us on February 21, 2025. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.

Upon receipt of the complaint, we reached out internally to view the member’s concerns. Appeal *********** was overturned on February 17, 2025. The claim was rekeyed in and processed under Claim ******** and Check ******** in the amount of $483.06 (including $.24 interest) was sent on February 21, 2025. Please allow 7 to 10 business days to receive.
The member will receive a detailed Medicare Resolution Letter within 7-10 business days.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ****** concerns.
Sincerely,
Cindi D
Analyst
Medicare Executive Resolutions
Customer Answer
Date: 02/24/2025

Better Business Bureau:

I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me.

Sincerely,

******* ****
Initial Complaint
Date:02/20/2025
Type:Order Issues
Status:
ResolvedMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
I have Medicare with Aetna, with a ***** plan. Aetna disenrolled me from my plan. I have Medicaid & I recertify every year. My Medicaid expires on June 30, 2025. I called Medicaid & requested a letter sent to Aetna. The letter sent to Aetna from Medicaid was also sent to me. I called Medicare & I was told I was not to be disenrolled. I am having a lot of issues no one seems to know what’s going on or what to do. My Aetna ID # is ************. I am told to call ********, which I have done numerous times. ******** in turn tells me to call Aetna. It’s just a constant back & forth & no one HELPS. I will be contacting Medicare again as I end this complaint. I am presently on the phone with Amanda from member services, she doesn’t know what’s going on either. Aetna I am getting to find out is a LOUSY INSURANCE.
Business Response
Date: 02/25/2025
**** *** ******* **********

Please see our response to complaint # ******** for Ms. ******* ******, which we received on February 20, 2025. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.

Upon receipt of the concern, we immediately reviewed the member’s enrollment details. Your Aetna Medicare Assure Plan (HMO *****) was terminated on January 31, 2025. We sent a notice to the PO Box on file on December 13, 2024. The notice advised that we learned you no longer qualify for Medicaid, or your level of Medicaid is not accepted by our plan. Because you need to qualify for Medicare and Medicaid to be a member of our plan, your coverage with us will end on January 31, 2025. The notice advised that you have until January 31, 2025, to requalify for Medicaid with your state to remain in the plan.

We understand that you completed your recertification with Medicaid. However, there was a change in your Medicaid ID. The plan did not receive the updated Medicaid ID prior to the deadline of, January 31, 2025. The plan was terminated correctly on January 31, 2025. We have received your new enrollment application. Your coverage with Aetna Medicare Assure (HMO *****) will begin on March 1, 2025.

The member will receive a written resolution letter within 7-10 business days.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. ******’s concerns.

Sincerely,
Jasmine W.
Analyst
Medicare Enterprise Resolution

Customer Answer
Date: 02/27/2025

Better Business Bureau:

I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me.

Sincerely,

******* ******
Initial Complaint
Date:02/19/2025
Type:Customer Service Issues
Status:
AnsweredMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
As of January 1, 2025 my insurance provider, Aetna Medicare Advantage, began using *** OTC Benefits as their extra benefits provider for members. Members are supposed to have a physical card, similar to a prepaid debit card on which our monthly allowance for benefits is loaded on the 1st of each month. Due to being homeless I did not receive my card prior to January 1, 2025. I contacted customer service and provided them with a mailing address where I requested they send me a new card. After several weeks I had not received the reissued card so I contacted them again and apparently they sent it to my former address again. Completely disregarding my repeated attempts to remove said address from my account. I requested yet another card to be sent again to an address I provided that is a friend's home address where I can receive mail. I reiterated my homeless situation and was ensured the card would be mailed to the address of my friend and not to either former address they strangely refuse to delete from my account. Weeks have gone by yet again and still no card. I called AGAIN and was told they sent it to the incorrect address. They refuse to assist me in obtaining a physical benefits card as provided by my insurance Aetna Medicare Advantage. They refuse to provide me with the card information so I can add the card to my payment method for accounts where I can use the benefits card. They refuse to help me get online and access my account. They have cost me $170 for January's benefits that I wasn't able to use. They do not ever provide the call back from a supervisor when promised. They do not make any attempts to remedy my situation that they alone are responsible for.
Business Response
Date: 03/04/2025
**** *** ******* *********:

Please see our response to complaint # ******** for *** ****** *******, which we received on February 19, 2025. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.

Upon receipt of the concern, we immediately reviewed the member’s Aetna Medicare Extra Benefits. Members get an Extra Supports Wallet with a $170 monthly benefit amount (allowance) on the Aetna Medicare Extra Benefits Card to pay for Healthy foods including meat, produce, dairy products, and more. Approved healthy food can be purchased in******;store at participating retail stores and online at ***.********* or by phone at ******************************** (TTY: ****. Members will receive a new card in the mail. It will include instructions on how to activate and use the card. It is the member’s responsibility to ensure that Aetna has the most up******;to******;date mailing address on file. Aetna is not responsible for misdirected, lost, or undelivered mail. Aetna is not responsible for lost or stolen cards and any use associated with the card thereafter. If a member needs a replacement card, please call 1******************************* (TTY: **** to request a new card. In the meantime, members can access certain benefits by visiting ***.*********.

We ask that the member review her Evidence of Coverage booklet for more information about this benefit and all other benefits offered by the plan.

We have reviewed the member’s call history to the plan. We found that Ms. ******* contacted the Customer Service Team on, January 1, 2025. The member was transferred to the OTC Department for assistance with how to use her benefits. The member advised that she did not currently have an address to ship the payment card. On February 13, 2025, the member contacted the plan because she did not receive her payment card. The representative she spoke to advised that she would file a complaint on the member’s behalf. Unfortunately, the representative failed to escalate the member’s concerns properly. We have taken the appropriate action with the representative for service improvements. The member contacted the plan on February 15, 2025. The member expressed concern about not receiving her payment card after updating her mailing address with *** ****** *********. The representative the member spoke with on February 15, 2025, filed a complaint on the member’s behalf. The representative updated the mailing address on the member’s account. As a result of the complaint, the Complaints team requested a new payment card be sent to the updated mailing address.

We contacted *** ****** ********* for more details. We provided the member’s concerns about customer service. *** ****** ********* advised that the member’s replacement card was issued on, February 15, 2025. The member called *** ****** ********* on February 18, 2025. An agent explained that they can activate the card to use the Cardless Payment option while waiting on the physical card. If a member is not able to wait the 14 days for the card to be delivered, they can use the Cardless Payment option after 2 days from the replacement card request.
-The Cardless Payment option is available by downloading the *** ****** ********* ***.
-The Cardless Payment allows for the members card to automatically populate in the Shop checkout experience.
-The Cardless Payment can only be used through the mobile app, in-store or online.

On February 18, 2025, the member was issued a rollover allowance of $170 for January. As of February 18, 2025, the member had an available balance of $340 on her Aetna Medicare Extra Benefits Card to use until the end of February.

The member will receive a written resolution letter within 7-10 business days.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. ********* concerns.

Sincerely,
Jasmine W.
Analyst
Medicare Enterprise Resolution
Initial Complaint
Date:02/18/2025
Type:Billing Issues
Status:
ResolvedMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
Beginning in 2025, Aetna started processing my insurance claims as out-of-network, despite acknowledging that they should have been processed in-network. As a result, I currently have eight claims that were incorrectly processed, leading to significantly higher bills from my providers—amounting to thousands of dollars more than if they had been handled correctly.

I have been in contact with Aetna for several weeks, but I feel like I am being given the runaround. I have been assured multiple times that my claims would be reprocessed, yet no action has been taken, and no one at Aetna can provide an explanation for the delay.

The claim IDs are:
-*********
-*********
-*********
-*********
-*********
-*********
-*********
-*********
Business Response
Date: 02/27/2025
**** *** **********

Please see our response to complaint # ******** for ****** ****** that was received by us on February 18, 2025. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We reviewed the member’s claim concerns and identified that the claims in 2025 were processed incorrectly as out-of-network due to an internal system error. We have corrected this internal system error to avoid any future claims being processed incorrectly. We confirmed that all claims were reprocessed as in-network and both the member and provider will receive updated explanation of benefits (EOB). In addition, we reviewed calls related to this concern and identified that the calls were handled correctly.

I apologize for any difficulties and inconvenience this situation has caused. We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. ******’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at: ********************************

Sincerely,

Lisa B.
Analyst, Executive Resolution
Executive Resolution Team

Customer Answer
Date: 02/27/2025

Better Business Bureau:

I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me.

Sincerely,

****** ******
Initial Complaint
Date:02/18/2025
Type:Order Issues
Status:
AnsweredMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
Switched from ***** to Aetna. ***** paid my doctor over 50 dollars and now Aetna pays them 20.00. I have to make up the rest.

They brag about their 45.00 otc benefits. Went to use that to by ***** ******. Guess what? Not covered

This is nowhere near quality insurance
Business Response
Date: 02/18/2025
**** *** ******* **********

Please
see our response to follow-up on complaint #******** for
*** ***** ***** that was received by us on February 18,
2025. Our Executive Resolution Team researched the concerns, and I would
like to share the results of the review with you below.

Upon
receipt of the complaint, we immediately reviewed member’s account. We have
confirmed Mr. ***** enrolled into an Aetna Medicare Premier PPO plan with an
effective date of January 1, 2025, and the plan is currently active.

As the member does not mention which doctor, that he is
referring to, we reviewed his recent call history on the his account. We
located three inbound calls made into our customer service department.

The first call, on February 6,
2025, the member was inquiring about the timeline to cancel his plan because we
are not paying his provider for his mental health services for date of service
January 27, 2025. Our customer service representative advised the member the
provider was paid on February 3, 2025, in the amount of $24.50, and his copay according
to his plan benefits for outpatient mental health services is $40. The member
was also advised that it is Open Enrollment Period. The Open Enrollment Period is a set time each year
when members in a Medicare Advantage plan can cancel their plan enrollment and
switch to another Medicare Advantage plan or obtain coverage through Original
Medicare. If members choose to switch to Original Medicare during this period, they
can also join a separate Medicare prescription drug plan at that time. Open
Enrollment runs from January 1, 2023, until March 31, 2023, where members can
make a onetime plan change that would start the 1st of the following month.

Please know the member can contact the ***** ****** ********* ********** ******* ******. **** is a government program
with trained counselors in every state. **** is an independent (not connected
with any insurance company or health plan) state program that gets money from
the Federal government to give free local health insurance counseling to people
with Medicare. **** counselors can help members understand their Medicare
rights, help members straighten out problems with their Medicare bills. SHIP
counselors can also help members with Medicare questions or problems and help them
understand their Medicare plan choices and answer questions about switching
plans. The member can contact his local **** at ###-###-#### or visit their
website at ****************

The second call was on February
17, 2025, and the member was inquiring about how to take advantage of his $45
quarterly over-the-counter allowance. The member was advised he can use the
benefit at any participating *** ********, he can also order online at
*******/Aetna and/or he can order by calling ###-###-####. The quarterly
allowance does not roll-over.

The third call was about being
advised that the brand Pepto-Bismol was not a covered item. Our customer
service representative transferred the member to our vendor, the OTC solutions
team to further assist the member.

We have confirmed the brand name
Pepto-Bismol is not a covered OTC item. However, we do show ******* Liquid and
Chewable tablets are listed as a covered item, on page 15 of the 2025 OTC
Catalog. Our members can get the most out of their OTC benefit using our mobile
app. Members can simply download the OTC Health Solutions app to get started.
It’s available on the *** ****** for ****** devices or on the ****** ****™
store for ******** devices. This app allows members to scan and view OTC
products offered, process an order, review past orders, and see their account
information. Members should refer to the OTC catalog to find products they want
to get. Only those listed in the catalog are available through their plan.
We have attached a copy of this members 2025 OTC catalog for his convenience.

The
member will receive a detailed Medicare Resolution Letter within 7-10 business
days with this response.

We
take customer complaints very seriously and appreciate you taking the time to
contact us and giving us the opportunity to address *** ***** *****’s concerns.

Sincerely,
Marilyn
Analyst,
Medicare Executive Resolution
Business Response
Date: 02/19/2025

Correction to "year" in previous response:
Open Enrollment runs from January 1, 2025 until March 31, 2025, where members can make a onetime plan change that would start the 1st of the following month.
Initial Complaint
Date:02/18/2025
Type:Customer Service Issues
Status:
AnsweredMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
i started new coverage. My children have orthodontist services. I called to verify coverage and was told prior to starting coverage my dependents would have coverage. My dependents had service and was denied that this was on going service. I then called and spoke with another person and they said that they were going to send the request in and it should be all taken care of. I then asked, if i would need to call in to get pre auth to go to their ortho, and the woman said no, once they update the system everything would be good. I did not hear anything back and got a run around. Theni called and REQUESTED TO SPEAK TO SOMEONE IN USA. I spoke to a lakesha and she was going to submit a request to have a manager review of the file for coverage. This was after the new year already. I heard nothing back and called again. I spoke to someone else and got different info. SO as of the new year, there is no more manager review for auth that it needs to be an appeal only. I was told this new policy stated 01/01/25 but this call was on i believe the 13th. Lakesha admitted she messed up, but it needs to go through appeal. again no accountability. Again i hear nothing, and called today 02/17/25, to be told a decision was made on 02/13/25. So they denied my claims again saying they did an investigation on the claim file, calls, etc. If the calls were all pull and monitored, you would hear the conversations that took place and what should be the right thing to do. This is not what me or anyone would expect from a health provider. Especially, when you have advocates stating coverage binders that leads the consumer to believe one thing and then be told another. While im writing this i been on a call for 45 min in which only been 10 min of real talk time speaking to someone in india that can not help.

I want information on the steps and process of the investigation, all the call dates and times pulled as well what the notes where on each call that were listen to.
Business Response
Date: 02/28/2025
**** ******* **********
Please see our response
to complaint # ******** for ***** ***** that was received by us on February 18, 2025. Our Executive Resolution Team
researched your concerns, and I would like to share the results of the review
with you.
Upon receipt of the
complaint, we immediately reached out internally to further investigate the
member’s concerns. Our investigation began by reviewing the appeals on file for
Mr. *****’s children from January 28, 2025. After reviewing all the submitted
documentation, our decision was upheld due to the plan’s work in progress
exclusion. This means that any orthodontic work that started prior to the
effective date of the plan is not covered. Based on the information supplied
with the claims, the comprehensive orthodontic treatment started on January 23,
2024, which was prior to the members’ effective date of June 10, 2024. On page
four of Mr. *****’s Summary Plan Description (SPD) under "Class
D—Orthodontic Services" it states in part, "The Plan will not cover
services for an orthodontic procedure if an active appliance for that procedure
was installed before you were covered by the Dental Plan.”
Our investigation
continued with the receipt of a Department of Insurance complaint. Unfortunately, our regulatory team was unable to
handle the request since Mr. ***** has a self-funded plan. Instead, Mr.
*****’s concerns were reviewed through the applicable complaint and appeal
process, and he was notified of our decision on the appeal resolution letters
dated February 13, 2025.
Our investigation
concluded with the receipt of this Better Business Bureau complaint, and we
confirmed that the previous reviews were handled appropriately. We also
researched three claims for Mr. *****’s son that were processed in January
after the coordination of benefits (COB) was updated. The COB showed that Aetna
is secondary, thus nothing was paid on them because the member’s primary insurance
paid their full allowable amount. Mr. ***** was advised during a call on February
17, 2025, that his plan’s coordination type is maintenance of benefits which
means Aetna will only pay toward a claim if the primary insurance falls short
of paying their full allowable amount. Additionally, the primary plan’s allowed
rates are much higher than Aetna’s, therefore no reimbursement will be sent as
the secondary plan in this case.
Furthermore, we reviewed Mr. *****’s call history
and were unable to locate any calls made prior to the members’ plan going into
effect. Please know, the first call on file was made on December 5, 2024, and
per the member’s request, we have attached a copy of his call details.
We regret our decision could not be
more favorable. We take customer complaints very seriously and appreciate you
taking the time to contact us and giving us the opportunity to address Mr. *****’s concerns. If there are any
additional questions regarding this particular matter, please contact the
Executive Resolution Team at *******************************.
Sincerely,

Brittany
F.
Analyst,
Executive Resolution
Executive
Resolution Team
Initial Complaint
Date:02/12/2025
Type:Customer Service Issues
Status:
AnsweredMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
I was preapproved two weeks and they electronical sent it **** **** ******* I asked Aetna to call **** **** ****** but I keep getting the run around. I need my dentures. They continue to give me the run around. I would like email confirmation to know when it was sent to **** **** so I can make a appointment.
Business Response
Date: 02/14/2025
**** ** *** *********** *** ******* **********

Please see our response to complaint # ******** for *** ***** ****** that was received by us on February 12, 2025. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.

Upon receipt of the complaint, we reached out internally to view the member’s concerns. A preauthorization is not needed for you to get dentures. The provider submitted a predetermination on January 27, 2025. The dentures are showing a payment may be made to the provider. We have also confirmed the provider is getting paid for covered procedures when the member initially saw him.

We have also confirmed the codes on the predetermination of ***** and ***** are covered and can be found on a Page 95 of your Evidence of Coverage. We enclosed a copy of the page showing the procedures are covered for the member’s convenience. The member will receive a detailed Medicare Resolution Letter within 7-10 business days.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ******** concerns.
Sincerely,
Cindi D
Analyst
Medicare Executive Resolutions
Initial Complaint
Date:02/12/2025
Type:Order Issues
Status:
ResolvedMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
I am filing a complaint against Aetna for wrongfully denying coverage for my medically necessary hip surgery, despite extensive medical documentation proving the necessity of the procedure.

I suffered a right hip injury in June 2024, and after failing all conservative treatments—including physical therapy, medications, and pain management—an MRI confirmed a complete labral tear, femoroacetabular impingement (FAI), and a displaced labrum. My surgeon, *** ***** *******, has determined that surgery is the only option.

Aetna denied my initial claim on January 15, 2025, and denied my Level 1 Appeal on February 4, 2025, citing that I had not completed six weeks of physical therapy. However, I provided Aetna with a formal letter from ***** ******** ******* stating that PT will not be beneficial for my condition. Additionally, my surgeon submitted a Letter of Medical Necessity confirming that surgery is required. Despite this, Aetna has continued to deny my claim.

Aetna has also refused to reschedule a peer-to-peer review, ignored expert medical opinions, and is now using an arbitrary Alpha Angle measurement to deny part of the procedure. Even if CAM debridement is not covered, my surgeon has confirmed that the labral repair remains medically necessary and should still be approved.

I filed a formal complaint with the ******** ********** ** ********* and ********* ******** *****) on February 6, 2025, and Aetna has until March 8, 2025, to respond. Meanwhile, I remain in severe pain, struggling with mobility issues, and unable to live my normal life.

Aetna is deliberately stalling my case with unnecessary roadblocks. I am requesting immediate intervention to hold Aetna accountable for their bad faith denial and ensure that my medically necessary surgery is approved.
Business Response
Date: 02/17/2025
Dear
******* *********:

Please
see our response to complaint #******** for **** ******* that was received by us on February 12, 2025. Our Executive Resolution Team researched the concerns,
and I would like to share the results of the review with you.

Upon receipt of the complaint,
we immediately reached out internally to further research the member’s
concerns. We confirmed that the authorization review and level one appeal were
denied appropriately. There was no documentation provided in either review that
showed the member had completed physical therapy requirements. Please know, the
recently submitted letter from ***** ******** ******* was not included in the
initial records. The member’s second level appeal request (dated February 10,
2025) including the additional documentation, has been received and is
currently under review. This review can take up to 15 calendar days for a decision
to be made. Furthermore, documentation showing Alpha Angle > 50 to show comprehensive
arthroscopic management (CAM) impingement would still be needed for consideration
of the additional procedure code. Should the member have any questions regarding
the status of his second level appeal, he may contact member services by
dialing the phone number on the back of his member identification card.
An optional
peer-to-peer review may be scheduled within 14 days after being offered. Please know, this is a strict deadline and cannot be extended. Our
clinical team spoke with the provider’s office on January 16, 2025, and provided
them with the guidelines for a peer-to-peer review. Afterwards, our clinical
team followed up with the provider’s office twice on January 27, 2025, and left
a voice message reminder regarding the review as well as provided their appeal
rights. Unfortunately, the provider’s office did not contact Aetna regarding
the peer-to-peer review until February 6, 2025, which was after the allowed 14
days. Due to not meeting the deadline, the provider’s next step was to appeal.
We
take customer complaints very seriously and appreciate you taking the time to
contact us and giving us the opportunity to address Mr. *******’s concerns. If there are any additional
questions regarding this particular matter, please contact the Executive
Resolution Team at *******************************.

Sincerely,

Shay G.
Analyst,
Executive Resolution
Executive
Resolution Team
Business Response
Date: 02/17/2025
Dear
******* *********:

Please
see our response to complaint #******** for **** ******* that was received by us on February 12, 2025. Our Executive Resolution Team researched the concerns,
and I would like to share the results of the review with you.

Upon receipt of the complaint,
we immediately reached out internally to further research the member’s
concerns. We confirmed that the authorization review and level one appeal were
denied appropriately. There was no documentation provided in either review that
showed the member had completed physical therapy requirements. Please know, the
recently submitted letter from ***** ******** ******* was not included in the
initial records. The member’s second level appeal request (dated February 10,
2025) including the additional documentation, has been received and is
currently under review. This review can take up to 15 calendar days for a decision
to be made. Furthermore, documentation showing Alpha Angle > 50 to show comprehensive
arthroscopic management (CAM) impingement would still be needed for consideration
of the additional procedure code. Should the member have any questions regarding
the status of his second level appeal, he may contact member services by
dialing the phone number on the back of his member identification card.
An optional
peer-to-peer review may be scheduled within 14 days after being offered. Please know, this is a strict deadline and cannot be extended. Our
clinical team spoke with the provider’s office on January 16, 2025, and provided
them with the guidelines for a peer-to-peer review. Afterwards, our clinical
team followed up with the provider’s office twice on January 27, 2025, and left
a voice message reminder regarding the review as well as provided their appeal
rights. Unfortunately, the provider’s office did not contact Aetna regarding
the peer-to-peer review until February 6, 2025, which was after the allowed 14
days. Due to not meeting the deadline, the provider’s next step was to appeal.
We
take customer complaints very seriously and appreciate you taking the time to
contact us and giving us the opportunity to address Mr. *******’s concerns. If there are any additional
questions regarding this particular matter, please contact the Executive
Resolution Team at *******************************.

Sincerely,

Shay G.
Analyst,
Executive Resolution
Executive
Resolution Team
Customer Answer
Date: 02/18/2025

Complaint: ********

I am rejecting this response because Aetna’s initial denial and Level 1 Appeal decision were made without considering the ***** ** letter, which confirms that physical therapy is not a viable treatment option for my condition. While I understand that this document was not part of the original appeal, it has now been submitted as part of the Level 2 Appeal, and I expect Aetna to review it fairly. Additionally, Aetna is continuing to cite the Alpha Angle measurement as a reason for denial, despite my surgeon confirming that labral repair is necessary regardless. Given the significant pain, mobility issues, and impact on my mental health, I request an expedited review to avoid further unnecessary delays. I will consider this matter resolved only when Aetna has completed a full and fair review of my case with all medical documentation included

Sincerely,

**** *******
Customer Answer
Date: 02/18/2025

Complaint: ********

I am rejecting this response because Aetna’s initial denial and Level 1 Appeal decision were made without considering the ***** ** letter, which confirms that physical therapy is not a viable treatment option for my condition. While I understand that this document was not part of the original appeal, it has now been submitted as part of the Level 2 Appeal, and I expect Aetna to review it fairly. Additionally, Aetna is continuing to cite the Alpha Angle measurement as a reason for denial, despite my surgeon confirming that labral repair is necessary regardless. Given the significant pain, mobility issues, and impact on my mental health, I request an expedited review to avoid further unnecessary delays. I will consider this matter resolved only when Aetna has completed a full and fair review of my case with all medical documentation included

Sincerely,

**** *******
Business Response
Date: 02/18/2025
Dear Mr. ******* *********:

Please see our response to complaint
#******** for **** ******* that was received by
us on February 18, 2025. Our Executive
Resolution Team researched your concerns, and I would like to share the results
of the review with you.

Upon
receipt of your request, we have confirmed that the member’s level two appeal is
under review per case *************. Mr. *******’s appeal request is being monitored
under the Executive complaint *************. Once there is a determination of
the appeal, Mr. ******* will be notified directly via email.

We take customer complaints very
seriously and appreciate you taking the time to contact us and giving us the
opportunity to address Mr. *******’s
concerns. If there are any additional questions regarding this particular
matter, please contact the Executive Resolution Team at *****************.

Sincerely,

Marshell H.
Analyst, Executive Resolution
Executive
Resolution Team
Business Response
Date: 02/18/2025
Dear Mr. ******* *********:

Please see our response to complaint
#******** for **** ******* that was received by
us on February 18, 2025. Our Executive
Resolution Team researched your concerns, and I would like to share the results
of the review with you.

Upon
receipt of your request, we have confirmed that the member’s level two appeal is
under review per case *************. Mr. *******’s appeal request is being monitored
under the Executive complaint *************. Once there is a determination of
the appeal, Mr. ******* will be notified directly via email.

We take customer complaints very
seriously and appreciate you taking the time to contact us and giving us the
opportunity to address Mr. *******’s
concerns. If there are any additional questions regarding this particular
matter, please contact the Executive Resolution Team at *****************.

Sincerely,

Marshell H.
Analyst, Executive Resolution
Executive
Resolution Team
Customer Answer
Date: 02/19/2025

Better Business Bureau:

Thank you for your follow-up regarding my complaint against Aetna. I have reviewed their latest response and am confirming that my issue has been resolved with the approval of my surgery.
I appreciate the assistance from the BBB in helping to facilitate this process, and I am grateful for the outcome. Please consider this matter closed on my behalf.

Sincerely,

**** *******
Customer Answer
Date: 02/19/2025

Better Business Bureau:

Thank you for your follow-up regarding my complaint against Aetna. I have reviewed their latest response and am confirming that my issue has been resolved with the approval of my surgery.
I appreciate the assistance from the BBB in helping to facilitate this process, and I am grateful for the outcome. Please consider this matter closed on my behalf.

Sincerely,

**** *******
Initial Complaint
Date:02/12/2025
Type:Order Issues
Status:
AnsweredMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
I have been trying to cancel my Prescription Drug Coverage with Aetna since December 16,2024. I have contacted the company 3 times with no results and although they made promises to take care of this problem, they have failed to do so. My premium increased 500% this year and I don’t want this coverage at that price. It is conveniently taken out of my Social Security benefits every month, so unless I can get them to cancel it, I’m still paying for it.
Business Response
Date: 02/19/2025
**** *** ******* **********

Please see our response to complaint # ******** for Ms. ******** ********, which we received on February 12, 2025. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.

Upon receipt of the concern, we immediately reviewed the member’s enrollment history. We found that Ms. ******** was enrolled with SilverScript Choice (PDP) from August 1, 2024, until December 31, 2024. We understand that our former member made a request to end her prescription drug coverage with the plan. Please advise, all disenrollment requests from members must be received in writing. A disenrollment form was mailed to the address on file on, December 21, 2024. Another disenrollment formed was mailed on, January 8, 2025. On January 26, 2025, we received the request to be disenrolled from SilverScript Choice (PDP). We sent a written notice to let Ms. ******** know that she would be disenrolled starting January 1, 2025.

Ms. ********’s monthly premium was set to be deducted from her Social Security check for the 2025 plan year. It may take two or more months for the deduction to stop. If a refund is due, the ****** ******** ************** ****) will provide a refund directly to Ms. ********. It can take two or more months for the Social Security Administration to issue a refund. The Plan is not able to provide this refund.

Ms. ******** was sent an Annual Notice of Change at the address on file on September 17, 2024. The Annual Notice of Change (ANOC) gives a summary of changes to the member’s benefits and costs for next year compared to their current benefits. All changes are effective January 1st. We encourage members to review and make any changes during the Annual Election Period (AEP). The Annual Election Period (AEP) runs from October 15 - December 07 each year. Beneficiaries can use this to either enroll in or disenroll from plans and return to Original Medicare. Elections become effective January 1 of the coming year.

According to the 2025 Annual Notice of Change, the monthly plan premium for the 2024 plan year was, $9.90. The monthly plan premium for the 2025 plan is, $44.90. Ms. ******** also has a Late Enrollment Penalty fee added to her monthly premium amount. The Late Enrollment Penalty is added by Medicare.

There are many factors that can cause a plan monthly premium to increase. Our desire is to be a cost-effective option for our members. In designing a plan, we take many factors into account. Every member has different needs, and we attempt to offer a balanced plan to meet those needs. We strive to offer a good value for the coverage you are receiving. In 2025, the SilverScript Choice (PDP) no longer has a Coverage Gap stage.

During the 2025 plan year, there are only 3 stages in the prescription drug plan.
Stage 1: Deductible - Members must pay the full negotiated cost of their drugs until they reach the plan’s deductible amount, which is $590.
Stage 2: Initial Coverage Stage - Members stay in the Initial Coverage Stage until their total drug costs for the year reach $2,000.
Stage 3: Catastrophic Stage - Members qualify for the Catastrophic Coverage Stage when out-of-pocket costs have reached the $2,000 limit for the calendar year. During the Catastrophic Coverage Stage, members pay nothing for their covered Part D drugs.

The member will receive a written resolution letter within 7-10 business days.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. ********’s concerns.

Sincerely,
Jasmine W.
Analyst
Medicare Enterprise Resolution

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