Seeking Non-Emergency Treatment
You are entitled to all medically necessary treatment that would be available to you on the NHS. Elective procedures (i.e. procedures that are not medically necessary) are not funded.
All non-emergency care must be with a provider in the Aetna Choice POS II network of healthcare providers and information on how to find a provider can be found here.
Some procedures/treatments/appointments are automatically covered and require no authorisation; however others require approval (from Defence Medical Services in the UK) before you receive treatment otherwise you may be required to pay the costs.
If you are unclear if a particular treatment is funded by the MOD, please contact the Healthcare and Education Department. We can then clarify your entitlement with Defence Medical Services in the UK.
You can also check the A-Z of Healthcare Coverage page for more information on what is and is not funded by the MOD.
The US equivalent of a GP is a Primary Care Physician. When you arrive in the United States, you do not have to register with a Primary Care Physician as you would do a GP in the UK. If you try to register, the doctor will want to schedule you for a ‘wellness check’, which – for adults – is not covered by our healthcare plan. Rather, you should not visit a doctor in the United States until you have a clinical cause to do so. At that time, you can find a doctor that is in the Aetna Choice POS II network (see Finding a Provider in the Aetna Choice POS II Network) and schedule your appointment.
When you call to schedule your appointment, the provider may ask you what type of insurance you have. You should tell them that you have a PPO (Preferred Provider Organisation) plan, administered by Meritain Health.
The following are automatically covered for adults without prior-authorisation:
- Primary Care Physician visits for diagnosis and treatment of an illness, or monitoring of a pre-existing condition
- Tests/scans to diagnose an illness or monitor an existing condition
- Measurement of vital signs (Blood Pressure, Temperature, Height, Weight)
If you are referred to a specialist, please read the guidance under ‘Referrals’ below before proceeding with the referral.
Wellness Checks – Adults
Wellness checks are medical exams aimed at preventing health problems in an apparently healthy person. Wellness checks for adults are not covered by our plan/funded by the MOD as they are not available on the NHS or deemed clinically necessary. Therefore, if your doctor recommends any routine testing not in relation to any symptoms or illness you must tell them that you are not covered for this and do not want the tests (unless you are prepared to pay for the tests yourself).
There are a small number of routine tests/scans that are available on the NHS. These are mammograms, colonoscopies, prostate cancer screening and gynaecological care exams. The MOD will fund these tests, but only within the age restrictions and frequency limitations detailed in the A-Z of Healthcare Coverage.
If you need to register with a Primary Care Physician (for example if you require ongoing treatment for a specific condition) and your doctor needs to carry out any tests, please ensure they code your visit as an ‘Initial Patient Evaluation/Visit’, rather than a ‘Wellness Check’ or ‘Physical Exam’ and codes the tests as diagnostic. Inform the Healthcare and Education Department that your doctor requires you to have the tests done. We can then inform Meritain of the requirement for the tests to ensure that your claim is approved and the tests paid for.
If your doctor refers you to see a specialist or to have a procedure at a diagnostic testing centre (such as an X-ray, MRI scan, CT scan, PET scan or blood test) you must verify that any provider you are referred to is also in the Aetna Choice POS II network. If your doctor refers you to a facility that is not in the Aetna Choice POS II network, you cannot go to that particular specialist/facility. You should contact Aetna to find an alternative specialist/facility that is in the Aetna Choice POS II network. Please note that you must check the provider’s network status yourself; your doctor will not do this for you.
If your doctor refers you for a specific specialty or procedure and there is not an in-network provider available, please contact the Healthcare and Education Department for authorisation to seek out-of-network care.
The following are automatically covered without prior authorisation:
- An initial consultation with a specialist
- Diagnostic procedures (including x-rays, MRI scans, CT scans, PET scans and blood tests) to diagnose an illness or monitor an existing condition
However, further appointments and treatment with a specialist do require authorisation.
Authorisation for non-urgent procedures
If your doctor or specialist recommends a non-urgent medical procedure, such as an operation (including both inpatient and outpatient/minor surgery), office surgery or a course of treatment, you will need approval from Defence Medical Services in the UK for your treatment before you receive care.
Email the Healthcare and Education team with documentation from your doctor including:
- the diagnosis
- the proposed treatment plan (including all pre-operative and post-operative care if surgery has been recommended)
- the desired outcome of the treatment
The Healthcare and Education team will forward this to Defence Medical Services who will then determine if the treatment is appropriate and would be available on the NHS. They may recommend an alternative treatment plan if the procedure/course of treatment your doctor has proposed is not available on the NHS. An answer is usually returned from Defence Medical Services within 48 hours of receiving a case, which the Healthcare and Education Coordinators will inform you of.
The Healthcare and Education Coordinators will also inform Meritain Health of all approved treatment to ensure this is paid for in full.
How is treatment paid for?
Whenever you receive healthcare, you must present your Meritain Health ID card to your medical provider. The medical provider will then bill Meritain Health for the cost of your care, who will process the claim and pay the medical provider directly. You should not have any out of pocket costs for medical treatment, as long as your medical provider is in the Aetna Choice POS II network and you receive approval for treatment where necessary.
If you receive any bills showing a patient responsibility other than $0 please contact the Healthcare and Education Department for assistance. Do not pay anything to the medical provider.
If you receive any non-emergency care from an out-of-network provider without prior authorisation from the Healthcare and Education Department, the cost of your treatment will be a personal expense.
Likewise, if you have any treatment that is not automatically covered before receiving approval, the cost of your care will be a personal expense.
The MOD will fund your prescriptions provided the drug (or an equivalent) is available on the NHS. You must present your Meritain Health ID card to the pharmacist when filling a prescription.
You’ll be charged a co-pay, which is the portion of a charge for prescriptions that is the patient’s personal responsibility to pay, which you pay direct to the pharmacy. It is equivalent to an NHS contribution in the UK and is currently: $12 per item.
Please note that the cost of the drug (ingredient cost plus dispensing fee) may be less than $12. If this is the case, you will only be charged for the actual cost of the drug.
If you are charged more than the co-pay amount at the pharmacy, please contact the Healthcare and Education Department for assistance.
You should not be charged anything for prescribed contraceptive drugs.
If you are exempt NHS charges, please inform the Healthcare and Education Department, providing proof of your exemption (e.g. exemption certificate) where necessary. Your exemption will be noted in Meritain Health’s prescription management system, and you will not be charged a co-pay whenever you fill a prescription for the duration of your exemption.