Aetna a great value for City of New York employees

Transcription

1 Aetna a great value for City of New York employees Aetna HMO Plan Benefits CCG CITYNY-0002 (10/11)

2 We all have busy lifestyles. The Aetna health plan makes things easier. Why choose a health benefits plan that s only affordable when you don t use it? When you choose Aetna, you get predictable costs from the basics to the biggies. Plus, plenty of features to help you protect your family s health and your budget from the what ifs. Aetna s Account Executive for the City of New York. For details, call or go to Health benefits plans are offered and/or underwritten by Aetna Health Inc. (Aetna). 1

3 To Enroll Just fill out an application form, available from your benefits or personnel office, during your transfer period. If you have any questions, call the toll-free Member Services number at For the hearing impaired, call (TDD) Enrollment in the Aetna health benefits plan puts these advantages at your fingertips... Exceptional MEMBER SERVICES Over 57,000 doctors in the tri-state area Access to major hospitals and facilities like Sloan-Kettering, Mount Sinai and New York Presbyterian Our DocFind online directory Online tools to help you check your claims, compare hospitals, find a doctor, order ID cards and more Cost-saving FEATURES $0 copays for preventive care Lower $15 PCP and $20 Specialist office visit copay for in-network care $100 toward prescription eyewear every 24 months Option to select our prescription drug program with no annual limit Savings on the Jenny Craig weightloss program, hearing aids and chiropractic visits Discounts on natural products like vitamins and supplements Savings on alternate medical services Free Health Assessment Benefits for GOOD HEALTH 100% preventive care coverage Emergency coverage anytime, anywhere 24-hour, toll-free Informed Health Line for health information day or night Our maternity management program Direct access to your Ob/Gyn no referrals required Support for more than 35 chronic conditions 2

4 How the Aetna HMO Works It s easy-to-use coverage, for one-on-one care. A primary care doctor will guide your way. Here s a health benefits plan from Aetna that lets you work with a primary care provider (PCP). It s as easy as 1, 2, 3. S T E P # 1 : Choose a PCP Your PCP is the doctor you go to first. He or she will help you learn about your health and how to manage it. You can choose any PCP from the Aetna network. Plus, it s good to know that anyone you choose meets our standards. Choosing a doctor is a personal decision that s why each member of your family can have his or her own PCP. You can change your PCP at any time. Just call Aetna s Member Services at the number on your ID card. Or, visit our secure member website at You must choose a PCP and see network providers to receive benefits through this plan. S T E P # 2 : 3 Visit your PCP for care Go to your PCP for checkups, or whenever you are sick or hurt. Your PCP will help you decide if you need care from another doctor. If so, he or she will give you a referral. Sometimes you may need care that requires approval from Aetna before you get it. Your PCP and other network doctors will get this approval for you. S T E P # 3 : Pay your copay When you visit the doctor, you pay a copay. This is a set amount you pay for each visit. See the Summary of Benefits on page 4 for your covered services and copay amounts. Finding a PCP is easy! Find one online With our DocFind online directory, you can look for a doctor by specialty and location. All the information you need is there including maps and directions to the doctor s office. You can even look for doctors who speak your language. Check out DocFind on your custom City of New York website at Get a printed directory For a printed directory, call Member Services at For the hearing impaired, call (TDD) Your primary care doctor will get to know you and help you get the care you need. 3

5 PRIMARY CARE PHYSICIAN VISITS Office Hours After Hours/Home Visits SPECIALTY CARE Office Visits Diagnostic Outpatient Testing Outpatient Therapy OUTPATIENT SURGERY PREVENTIVE CARE Routine Physicals Routine Eye Exam Routine GYN Exam Mammogram Well-Child Care EMERGENCY ROOM HOSPITALIZATION Room and Board (semiprivate) Surgery and Anesthesia Medical and Surgical Specialist Care Diagnostic Testing MATERNITY First OB Visit Hospital MENTAL HEALTH Inpatient (35 days per 365-day period) Outpatient (20 visits per 365-day period) SUBSTANCE ABUSE Inpatient Rehabilitation Aetna HMO Plan Summary of Benefits $15 copay $20 copay $20 copay $20 copay $20 copay $75 copay* $0 copay $0 copay $0 copay $0 copay Covered in full $75 copay $300 per admission copay for inpatient services* $20 copay $300 per admission deductible* $300 per admission deductible* $20 copay per visit Detoxification: $300 per admission copay for acute phase of treatment; Rehabilitation: $300 per admission copay 30 days per year for alcohol and/or drug addiction $15 copay per visit; 60-visit** combined annual Outpatient Rehabilitation (60 visits per calendar year) maximum for alcohol and/or drug treatment SKILLED NURSING FACILITY HOME CARE CHIROPRACTIC CARE FINANCIAL Deductible: Single/Family Coinsurance Coinsurance Limit: Single/Family Annual Maximum Benefit $300 per admission deductible Covered in full $20 copay None None Not applicable None **Precertification required or benefits will be denied. **Connecticut $20 copay applies. 4

6 Exceptional MEMBER SERVICES Get your health information when you need it Our Member Services and online tools make it easy for you to get answers to your health care questions. Most importantly, these services are available all day, every day. Aetna member website Visit your secure, members-only website to get the health information you need fast! You can: Review your plan and benefits information. Print a summary of your doctor visits, medical tests, prescriptions and other activities to share with your doctor. Look up costs for office visits, medical tests, surgeries and more. Research prescription drugs and compare the cost of brand-name versus generic drugs. Compare hospitals in your area for certain diagnoses and procedures to help you decide where to get care. Access the Healthwise Knowledgebase for information on thousands of health topics in English and Spanish. Visit Aetna today, or take the FREE tour! Go to and click on Aetna Navigator Member Log In. Then under Why Register? click on Take a Tour. If you re already an Aetna member, you can go to Member Log In and enter your user name and password, or register. Plan for Your Health SM website During pivotal moments in life like when you are changing jobs, getting married or divorced, starting a family, or retiring you should take a close look at your health benefits. By taking control of your health benefits, you can make the right decisions to protect your health and your wallet. Plan for Your Health, a public education campaign from Aetna and the Financial Planning Association (FPA ), provides you with important information to help make health benefits and financial decisions that meet your needs now and in the future. Go to for more information. Aetna InteliHealth website With this interactive site, you can research health, dental and wellness information from sources you can trust including doctors from Harvard Medical School! Plus, you can sign up to receive FREE health s. Go to for more information. Informed Health Line talk to a registered nurse 24/7 at Available 24 hours a day, 7 days a week, the Informed Health Line gives Aetna members a quick, simple way to get answers to health and wellness questions from a trained team of registered nurses. While only your doctor can diagnose, prescribe or give medical advice, Informed Health Line nurses can offer information on more than 5,000 health topics. Always consult your doctor first with questions or concerns about your health care needs. 5

7 Cost-saving FEATURES Discount programs and services from Aetna Who said nothing in life is free? Enroll in the Aetna HMO Plan and get at no added cost Aetna extras! Our discount programs and services are your ticket to the small luxuries that can help keep you happy and healthy. A vision program for eye-opening savings See your way to bigger savings! Let the Aetna Vision SM discount program supplement your standard vision care benefits. You ll pay less for contact lenses, and prescription and non-prescription eyeglasses. Even most designer frames! Save at: JCPenney Optical LensCrafters Target Optical Sears Optical Pearle Vision Plus many doctors in private practice Save 20 percent on specialty items not typically covered by insurance like snazzy eyeglass chains, sunglasses and contact cleaners. For a complete list of participating stores, independent optometrists and ophthalmologists, go to and click on DocFind. Save on LASIK surgery LASIK surgery just got more affordable. Not only do you save on the surgery itself, the initial consultation is always FREE. These programs and services are not insurance, so there are no approvals or referrals needed and no claims to file! A complementary health care program to relax, recharge and save! Aetna Natural Products and Services SM discount program Few people travel the same path to good health. That s why the Aetna Natural Products and Services program delivers savings on complementary health services and natural products through American Specialty Health Networks, Inc., a recognized leader in this market. It s a smart way to save on items not typically covered by insurance. Programs include: Acupuncture Dietetic counseling Massage therapy Natural products Online consultations 6

8 A hearing discount program to hear the world clearly Aetna Hearing SM discount program Hear the world clearly with savings from the Aetna Hearing discount program. You ll save on the latest hearing aid styles and technology. You ll also get 40 percent off the retail price of hearing exams. It s everything you need to make your world sound clearer all brought to you by HearPO, a national hearing-benefits provider. You ll get: Savings on all hearing aid styles* Advanced technology on digital hearing aids from leading manufacturers Discounts on hearing aid batteries A 3-year warranty covering repairs, loss and damage Your choice of more than 1,000 digital hearing aid models Free follow-up services for one year Over 1,600** participating locations nationally If your health benefits plan covers hearing aids or exams, follow your plan instructions first. *HearPO will help you choose the best hearing aid for your needs. All manufacturers offer savings, but they may vary based on make and model. **HearPO website, 8/11 HearPO is the registered trademark of HearPO Corp. Find HearPO locations on DocFind, Aetna s online provider directory, available at Under Provider Category, select Hearing Discount, and under Provider Type, select Hearing Discount Locations, or call HearPO at for a referral to an area provider. A fitness program for your body... and budget Regular exercise can help you stay healthy and can make you look and feel better. With the Aetna Fitness SM discount program, you can save money, too! It s easy to get started once you ve enrolled with Aetna. Enjoy preferred rates on fitness club memberships in the GlobalFit network.*** Visit to find a location near you. ***Membership to a club of which you are a current member is not available. Further, membership may not be available to a club if you have been a member of that club within the past 12 months. More reasons to join our fitness program More than 10,000 gyms in the U.S. and Canada Convenient billing through your bank account or a major credit card Free guest passes (not available at all clubs) Guest privileges at participating gyms when you travel Savings on home exercise equipment and videos At-home weight loss and one-on-one health coaching programs provided by WellCall, Inc., through GlobalFit 7

9 A weight management discount program to look and feel better Looking to lose weight and feel better? The Aetna Weight Management SM discount program can help. You and your eligible family members can save on weight loss programs, plans and products from the world s leading weight management firms: ediets, Jenny Craig and Nutrisystem. You ll get everything you need for sensible weight loss: one-on-one professional consultations, discounts on weight loss products that fit your lifestyle, and much more. ediets Save 30 percent on online monthly plan membership dues. Save 15 percent on all purchases from the ediets Online Store, including DVDs, CDs, fitness and exercise equipment, and vitamins and supplements. Save 15 percent on the Meal Delivery Plan with customized menus. For more information on ediets, call Nutrisystem FREE online membership with access to various online tools, newsletter content, discussion boards and chat rooms. Save 12 percent on any 28-day meal plan* To sign up with Nutrisystem, call *Aetna discount offers do not apply to any program in which the member is already enrolled. To receive the discounted rate, you must wait until your current program ends. If you are enrolled in Auto-Delivery program, you must cancel it and then re-enroll to receive the discounted rate. More savings for you! Discounts on Waterpik Sensonic toothbrushes and Waterpik Ultra Water Flosser. Subscribe to and get 30 percent off a one-year membership. You ll get ratings on restaurants, hotels, movies, attractions and more. Save on newsletters or books from the bookstore. Jenny Craig Start with a FREE 30-day trial program Then, receive 25 percent off a Jenny Craig Premium Program* Call Jenny-70 ( ) to find the centre nearest you. *Food and shipping not included. Offer applies to initial membership fee only and is valid at participating centres in the U.S., Canada and Puerto Rico, and through Jenny Craig At Home. Each offer is separate and can be used only once per person. Restrictions apply. 888

10 Benefits for GOOD HEALTH Aetna Programs to Keep You Healthy The Aetna HMO plan available to City of New York employees now includes these disease management and maternity programs. Access to Prescriptions City of New York members enjoy a prescription drug plan with no annual limit. For a 30-day supply, you pay: $10 for generic medications 30 percent of the total cost of the drug for formulary brand-name medications, plus the difference between the formulary and generic price 50 percent of the total cost of the drug for non-formulary brand-name medications, plus the difference between the non-formulary brandname and generic price For 90-day supply through mail order delivery, you pay $20 copay for generic medications Brand-name medications and nonformulary brand-name medications are covered at the same level as noted above through mail order delivery. The Aetna national pharmacy network provides members with access to over 60,000 pharmacies located in 50 states, the District of Columbia, Puerto Rico and the Virgin Islands. You can look up participating pharmacies on DocFind or by contacting Member Services at the toll-free phone number on your member ID card. Support like never before Aetna Health Connections SM Disease Management Program Reach your own level of good health Not everyone can be perfectly healthy. But, even with an ongoing health condition, you can reach your own level of good health. Our disease management program can help. In this program, you can learn how to: Get the treatment and preventive care you need Understand and follow your doctor s treatment plan Better manage your ongoing conditions Make changes to reach your personal health goals Identify and manage your risks for other conditions Get support from nurses for a healthier you Our nurses and clinicians can support you even if you have more than one condition. You get this support all in one program, and you get: Educational materials mailed to you Online resources you can use anytime Nurse case management State-of-the-art technology that looks out for your health and safety Support for more than 35 conditions, including: Cancer Heart disease Digestive conditions Diabetes Low back pain And many others 9

11 How our program can work for you As an example, let s say you have diabetes. You may contact us to join. Or, we contact you to see if you want help managing your health issues. Our nurses then can: Teach you about and send you information on diabetes Give you online resources to use anytime Review the treatment plan and medications your doctor gave you Explain possible side effects and answer your questions Give you our 24-hour, toll-free disease management phone number Work with you over time to help you meet your goals for managing diabetes and other health conditions After speaking with a nurse, you will receive a letter. The letter will list points you discussed and steps you decided to take between doctor visits. Our support team can help you learn how to help protect yourself from future health problems. Give your baby a healthy start Beginning Right Maternity Program Our Beginning Right Maternity Program comes with your Aetna health plan. Use it throughout your pregnancy and after your baby is born. Learn what s best for a healthy pregnancy Receive educational materials on: Prenatal care Signs of preterm labor What to expect before and after delivery Newborn care and more Take our pregnancy risk survey to find out if you have any health conditions or risk factors that could affect your pregnancy. To give your pregnancy a healthy boost with Beginning Right, call CRADLE-1 ( ). If you are identified as at risk or high risk, you ll receive two follow-up calls after delivery. Your nurse case manager will check in to see if you and your baby are doing well. We can also do an initial screen for depression and give even more support if needed. We have nurses and other health educators who speak English and Spanish. Our translation service offers help in over 170 languages. Plus, you can receive program materials in English or Spanish. Go online and learn more about women s health Go to Aetna Women s Health online for information on pregnancy and baby care, as well as: Reproductive health Menopause Breast health Heart health Migraines Depression The more you know, the better chance you have for good health... for you and your baby. 10

12 Frequently Asked Questions about the Aetna HMO plan Q: Where can I find a list of doctors and hospitals in the network? A: You can use DocFind, our online directory of participating providers. This is the most up-to-date resource for finding participating doctors, hospitals, pharmacies and other medical providers and services. Check out DocFind on your custom City of New York website at Q: How can I change my PCP? A: You can change your PCP online or over the phone. To change your PCP online, simply access the DocFind directory at or go to You can send an electronic request to Aetna Member Services. This service is available 24 hours a day without waiting to speak to a Member Services representative. If you would like to notify us of your PCP change by phone, call Member Services at For the hearing impaired, call (TDD) Q: Where can I find out what my coverage or copay will be for certain procedures? A: Copay information can be found on your ID card and in your member enrollment materials. See the Summary of Benefits on page 4 in this brochure, as well as in the Certificate of Coverage. If you cannot find the information you need in either of those locations, call Member Services at For the hearing impaired, call (TDD) Q: What does Aetna consider an emergency? A: We have adopted the following definition of an emergency medical condition from the Balanced Budget Act of 1997: An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity... such that a prudent layperson who possesses average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in... serious jeopardy... to the person s health. If you experience an emergency, you should seek care at the nearest medical facility, then contact your PCP or doctor for follow-up care. For more information on this policy, please visit our website at 11

13 Q: Am I covered when I am outside my home service area? Can I see a participating primary care physician (PCP) in another area? A: Plan members, including covered dependents away from home, are covered for emergency and urgent care when outside their normal or home service area. (For a description of what Aetna considers an emergency, see previous question.) You can get emergency and urgent care from a doctor, a walk-in clinic, an urgent care center or an emergency facility. Although you are outside your home service area, you will still need to coordinate your care through your PCP. In case of an accidental injury or lifethreatening medical emergency where you are admitted to an inpatient facility, you (or someone on your behalf) should immediately notify your PCP. In other cases, your PCP should be contacted within 48 hours of the emergency. If you have any questions about our worldwide, 24-hour emergency coverage, please contact Member Services at For the hearing impaired, call (TDD) Q: What if I lose my ID card and have an appointment the same day? A: With just four simple steps you can access a temporary ID card. Log in or register with Aetna at Look under Request & Changes Select ID card Print your temporary ID card To have a permanent card mailed to you, just call Member Services at For the hearing impaired, call (TDD) Q: How can I find out if my claim was processed? A: Go to and log in or register. The Recent Claims section provides a quick view of the most recent claims on file. Each claim line includes the date of service, and patient and provider name. Click on the details link to access the Claim Details screen and view more information about the selected claim. There is also a link to search for other claims on file. Or, you can call Member Services at For the hearing impaired, call (TDD)

14 If you need this material translated into another language, please call Member Services at Si usted necesita este documento en otro idioma, por favor llame a Servicios al Miembro al This material is for information only. Health benefits plans contain exclusions and limitations. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. If you are in a plan that requires the selection of a primary care physician and your primary care physician is part of an integrated delivery system or physician group, your primary care physician will generally refer you to specialists and hospitals that are affiliated with the delivery system or physician group. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna s Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Discount programs provide access to discounted prices and are NOT insured benefits. The member is responsible for the full cost of the discounted services. Aetna may receive a percentage of the fee you pay to the discount vendor. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to Aetna Inc. CCG CITYNY-0002 (10/11)