Aetna $30 Copay Plan. How the Plan Works. In-Network Benefits. Out-of-Network Benefits. To Find a Network Provider

Transcription

1 The combines the advantages of managed health care with the freedom of traditional medical coverage. With the, every time you receive care, you can choose to receive it on an in-network or out-of-network basis. You have access to participating network providers through the Aetna POS network, a primary care physician (PCP), as well as out-of-network care. However, with the $30 Copay Plan, you are not required to have your care coordinated by a PCP. This document is an overview of what the covers and describes how the option works. How the Plan Works The provides you with the freedom to choose any provider; however, your choice of providers will determine how your benefits are paid. Benefits provided by in-network providers will be paid at a higher coinsurance level than benefits provided by an out-of-network provider. You will be responsible for any deductible, coinsurance and copayments that apply; however, you will not have to file claims. Network providers will accept the Plan s payment as payment in full. Out-of-network providers may balance bill the charges. The benefit period is from January 1 to December 31 in each year while the coverage remains in effect. The shares the cost of your health care expenses with you. In-Network Benefits When you receive in-network care through the, the following benefit features apply: You are covered at 100% for eligible preventive care. Contacting Aetna You may view an online provider directory at You usually don t have to file any claim forms; your network provider will usually file claim forms for you. Your deductible and out-of-pocket expenses will be lower compared to your expenses for the same type of care on an out-of-network basis. Doctor s office visits are subject to a copay only; the deductible does not apply. The doctors have agreed to accept negotiated fees that are generally lower than what you would pay for out network; as a result, reasonable and customary (R&C) fees do not apply. To Find a Network Provider To see if your doctor participates in the Aetna network or to find a network provider, log onto Once you log on, select type of provider you are looking for and enter your zip. A drop down box will appear to select the type of plan you will find the plan under Aetna Open Access Plans Aetna Choice POS II (Open Access). Out-of-Network Benefits Under the, you can choose to visit an out-of-network physician, hospital, or other provider at any time. If you choose to receive covered services on an out-of-network basis: Services performed by providers not participating in the network will be reimbursed at the out-of-network level of benefits, based on reasonable and customary (R&C) limits, for covered services. 1

2 The deductible you need to meet in order to get reimbursed is higher for out-of-network providers than if you used an in-network provider. You are responsible for any amounts above the R&C limits. You ll need to file a claim form to receive out-of-network benefits. You ll need to obtain any required authorization or precertification for services as well as authorizations for hospital admissions. Your costs for medically necessary covered services generally will be higher than if you received innetwork care. Copayments Copayments are the amounts you must pay directly to a provider when you receive in-network services. The Plan s payment will be reduced by the amount of the copayment. For office visits to out-of-network physicians, a copayment does not apply. Benefits for office visits to out-of-network physicians will be paid according to the standard payment provisions for out-of-network physicians. All medical copayments will apply to the out-of-pocket maximum. Annual Deductible The deductible is the initial amount of medical expenses that you must pay before you will receive benefits under the Plan. Under the, the deductible applies once to each covered person in a benefit period. However, the total deductible for a family in any one benefit period will not be more than the family. The family deductible can be satisfied by any combination of expenses from either all or some of the family members, except that no individual can contribute more than the individual deductible amount. If one family member meets the individual deductible, the Plan will pay for that person s additional covered medical expenses, even if the deductible for the entire family has not been met. Under the, eligible expenses charged by in-network providers apply towards the innetwork deductible only. Out-of-network expenses apply only to the out-of-network deductible. Coinsurance and Maximum Benefits After you have met your deductible, you share in paying the balance of covered medical expenses. This is called your coinsurance. The amount of coinsurance you pay will vary whether services are provided by an innetwork or out-of-network provider, and possibly whether the services are supplemental services (e.g., durable medical equipment). The Plan will pay a percentage of the applicable allowance for covered medical expenses incurred by each covered person in excess of the deductible. The Plan s coinsurance amounts are shown in How the Plan Pays Benefits below; you will be responsible for the remainder. For Example If the Plan s coinsurance is 80%, the coinsurance you will be responsible for will be 20%. In addition, if aggregate covered medical expenses paid by a covered person in a benefit period exceed the out-of-pocket limit, as shown in How the Plan Pays Benefits, the Plan will pay 100% of the Plan s applicable allowance for covered medical expenses thereafter incurred by that covered person in that benefit period. When the total family out-of-pocket amount is reached, the Plan will pay 100% of the Plan s applicable allowance for covered medical expenses thereafter incurred by other covered persons enrolled under the same family coverage during that benefit period. Eligible expenses charged by in-network providers apply towards the in-network out-of-pocket limit only. Out-of-network expenses apply only to the out-of-network out-of-pocket limit. 2

3 The out-of-pocket limit cannot be met with non-covered charges. The following table identifies what does and does not apply toward your out-of-pocket limit. Copays (medical only) Payments toward the annual deductible Coinsurance payments (medical only) Charges for non-covered health services Any that exceed eligible expenses Apply to the Out-of-Pocket Limit? Yes Yes Yes No No How the Plan Pays Benefits The level at which benefits are paid depends on whether you receive your care in-network or out-of-network. The table below details how treatments and services are covered. Unless otherwise noted, deductibles and outof-pocket maximums apply to the coverages shown in the table. For out-of-network services in the Plan, coverage is based on the Plan s eligible expenses. You are responsible for the remaining coinsurance and any charges over the eligible expenses. Deductible Annual Out-of-Pocket Limit (includes deductible and copays) Lifetime Maximum Benefits Per Person $300 per person $900 per family $3,000 per person $9,000 per family No Lifetime Maximum $3,000 per person $9,000 per family $9,000 per person $27,000 per family Doctors Office Visits 100% after $30 copay per visit Specialist Office Visits 100% after $40 copay per visit Preventive Care (Physicals, well-child care, immunizations, routine cancer 100% no copays screenings, annual gynecological exams [including Pap smears], routine mammography, routine colonoscopies, prostate cancer screening, hearing exams, etc.) Acupuncture 80% after deductible Allergy Testing and Treatment 80% after deductible Ambulance Services For true emergency 80% after deductible 80% after deductible For non-emergency 80% after deductible Ambulatory Surgery 80% after deductible Anesthesia 80% after deductible Assistant Surgeon 80% after deductible Blood (blood, blood products, blood transfusions, testing, processing) 80% after deductible 3

4 Chiropractic Care (Therapeutic Manipulations) (up to combined maximum of 45 visits per year for speech therapy, physical therapy, occupational therapy, and chiropractic services) 100% after $40 Specialist copay Congenital Heart Disease (CHD) Surgeries 80% after deductible Consultation Inpatient 80% after deductible Outpatient 80% after deductible Dental Care (Dental in nature oral surgery Treatment from physician or dentist for accidental injury to sound natural teeth when performed within 12 months of injury date. Surgical and non surgical treatment of TMJ and carniomandibular disorder on same basis as any other body joint. Treatment of cleft lip and palate for dependent child under age 18.) Inpatient 80% after deductible Outpatient 80% after deductible Diabetes Benefits Dialysis Center Charters For diabetes self-management and training/diabetic eye examinations/foot care, benefits depend on where services are provided as described throughout this table. For diabetes self-management items, see Durable Medical Equipment. Some items are covered under the prescription drug benefits. Outpatient Professional Services 80% after deductible Outpatient Facility Charges 80% after deductible Durable Medical Equipment 80% after deductible Unlimited Hearing Aids 100% after deductible up to a maximum of $500 per calendar year Foot Orthotics 80% after deductible Up to a $750 maximum per calendar year Wigs (covered for hair loss due to injury, disease, or treatment of a disease only) Emergency Room Services True Emergency (copay waived if admitted) Non-Emergency (copay waived if admitted) 100% no deductible, copay waived with a reimbursement of up to $500 per calendar year 80% after $150 copay per visit, no deductible 80% after $150 copay per visit and after deductible 80% after $150 copay per visit, no deductible 60% after $150 copay per visit and after deductible 4

5 Facility Charges (365 days inpatient hospital care, subject to approval) 80% after deductible Home Health Care 80% after deductible Up to180 visits per calendar year (in- and out-ofnetwork combined) Hospice Care 80% after deductible Unlimited visits per calendar year Hospital Care Inpatient 80% after deductible Infertility Services (diagnosis and treatment of underlying causes only) Inpatient 80% after deductible Outpatient 80% after deductible Inpatient Physician Services (during a covered admission) 80% after deductible Lab/X-ray/Pathology Routine Inpatient Professional Services 100%, no copay Outpatient Professional Services 100%, no copay Outpatient Facility Charges 100%, no copay Lab/X-ray/Pathology Non-Routine Inpatient Professional Services 80% after deductible Outpatient Professional Services 80% after deductible Outpatient Facility Charges 80% after deductible Lab, X-ray and Major Diagnostics CT, PET, MRI, MRA and Nuclear Medicine - Outpatient Maternity Care Professional Services 80% after deductible 100% after $30 PCP copay (copay applies to first prenatal visit only) Hospital/Facility Charges 80% after deductible Mental Health Services Inpatient and Intermediate Mental Health Services Outpatient Nutritional Counseling Up to 6 visits per calendar year (in- and out-of-network combined) 80% after deductible 100% after $30 PCP copay 100% after $40 Specialist copay Obesity Surgery 80% after deductible 5

6 Organ Transplant 80% after deductible at an approved Institutes of Excellence (IOE) Transplant Facility at a participating Aetna facility but not an IOE Transplant Facility Ostomy Supplies 80% after deductible Oxygen Administration 80% after deductible Physician s Office Services Sickness and Injury (in addition to the office visit copay for network providers, the copays and coinsurance described elsewhere in this table apply for specific health services performed in the physician s office e.g., diagnostic services and surgery) Physician Office Visits 100% after the applicable office visit copay 100% after $30 copay (no copay applies after first visit) Hospital Inpatient 80% after deductible Physician Fees for Surgical and Medical Services 80% after deductible 80% after deductible Practitioner or Physician s Assistant Charges for Surgery Inpatient or Outpatient Practitioner or Physician s Assistant Charges for Non- Surgical Care and Treatment Prescription Drugs Retail (through CVS/Caremark; 30-day supply; mandatory generic unless otherwise written at additional copay amount) Prescription Drugs Mail Order (through CVS/Caremark; 90-day supply, mandatory maintenance drug mail order; one initial fill and two refills - 3 rd refill is mail order) Private Duty Nursing 70 8-hr shifts per calendar year (in- and out-of-network combined) 80% after deductible 80% after deductible Generics: $10 copay Brand formulary: $25 copay Formulary: $40 copay Generics: $15 copay Brand formulary: $50 copay Formulary: $80 copay 80% minus copay 80% after deductible Prosthetic Devices 80% after deductible Rehabilitation Services (up to combined maximum of 45 visits per year for speech therapy, physical therapy, occupational therapy, and chiropractic services) Second Opinion Charges 100% after $40 copay Outpatient 100% after $30 copay Inpatient 80% after deductible Scopic Procedures Outpatient Diagnostic and Therapeutic 80% after deductible 6

7 Skilled Nursing Care Up to 120 days per calendar year (combined for in- and outof-network services) Substance Use Disorder Services Inpatient Professional Services Outpatient Professional Services Inpatient and Outpatient Facility Charges 80% after deductible 80% after deductible 100% after $30 copay 80% after deductible Surgical Services 80% after deductible Temporomandibular Joint (TMJ) Services 80% after deductible Therapy Injection 80% after deductible Therapy Physical Inpatient 80% after deductible Therapy Radiation, Chemo, Dialysis Outpatient Professional Services 80% after deductible Outpatient Facility Charges 80% after deductible Therapy Respiratory & Cognitive (cognitive therapy subject to 45 visits per benefit period) Outpatient Professional Services 100% after $40 copay per visit Outpatient Facility Charges 80% after deductible Urgent Care Center Services (in addition to the urgent care center copay, the copays and coinsurance described elsewhere in this table apply for specific health services performed in the urgent care center e.g., diagnostic services and surgery) Non-Urgent Use of Urgent Care Provider 80% after $75 UCF copay, no deductible 80% after $75 UCF copay and deductible 60% after $75 copay, no deductible 60% after $75 UCF copay and deductible Vision Care Exams Routine Vision Exam Only (1 per calendar year) 100% (no copay) Non-Routine Vision Exam Only 100% after $40 copay per visit Wigs See Durable Medical Equipment X-rays See Lab/X-ray/Pathology 7