Aetna Savings Plus Plan Guide

Transcription

1 Aetna Savings Plus Plan Guide For businesses with 2 50 eligible employees in Northeast Ohio Aetna Avenue Your Destination for Small Business Solutions Health Insurance plans are offered and/or underwritten by Aetna Life Insurance Company (Aetna). Plans effective August 1, OH A (8/11)

2 New health plans designed with small businesses in mind The Aetna Savings Plus plans are helping Northeast Ohio small businesses access health services that fit their needs and their budgets. They give members access to an affordable network of health providers right in their own community. Same quality local care at a lower cost The Aetna Savings Plus plans provide Northeast Ohio members with the same types of coverage as other Aetna medical plans, but at a lower premium cost. Savings are generated through the use of the Savings Plus network, a quality network of local health care providers. The plans also: n Cover doctor s visits, hospital stays and preventive care n Include prescription drugs n Provide access to a secure member self-service website How do the Savings Plus plans work? There are three different Aetna Savings Plus plans in Northeast Ohio, giving small businesses the flexibility and choice to best meet their needs. Savings Plus plans use the Aetna Managed Choice POS Open Access network. Each Savings Plus plan has three levels of benefits: n Level 1: When members use the Savings Plus network, they realize maximum savings. n Level 2: When members use the Non-Designated Network Providers, they realize standard savings. n Level 3: When members use out-of-network providers, they will see the highest member cost. While members have the freedom to receive care from any hospital or specialist, they realize the highest benefit level and the lowest out-of-pocket costs when they access care through the Savings Plus network. All Savings Plus plans include coverage for doctor s visits, hospital stays, preventive care, pharmacy and more. (Refer to the benefits summaries on pages 4 6 for more details.) Each plan offers three levels of benefits to your employees. Premiums and out-of-pocket expense levels vary select the plan that s right for you and your employees.

3 Aetna makes it easier to manage your health plan Savings Plus plans include access to a robust suite of resources and online tools that save you time and money while helping your employees make better health decisions. Easy-to-navigate plans Aetna s small group health benefits and insurance plans are easy to set up, administer and use. Once enrolled, you will have access not only to your health insurance benefits, but also to online resources and information to help you and your employees make more informed decisions about your health. Aetna e-business for plan sponsors Aetna will help you save time and manage your benefits through a suite of innovative, easy-to-use online tools, supporting enrollment transactions. The benefits enrollment process is easier than ever, replacing paper-based enrollment with a secure, comprehensive electronic solution. More benefits for small businesses Aetna s Savings Plus clients can tap into corporate buying power through Aetna s Resource Connection SM, which features discounted goods and services. While not insurance, these discounts* can help you save on office supplies, HR support, payroll, technology assistance and more. Let Aetna be your guide With 150 years of experience, we can deliver the right solution for your small business. * Programs provide access to discounted prices and are not insured benefits. 1

4 Aetna Savings Plus service areas for Northeast Ohio These benefits are available in portions of four Northeast Ohio counties. Lake County Ashtabula County Cuyahoga County Geauga County Cuyahoga County ZIP Code City Chagrin Falls Euclid Euclid Euclid Lyndhurst Mayfield Heights Euclid Solon Mayfield Mayfield Heights Mayfield Village Euclid Highland Heights Lake County ZIP Code City Grand River Madison Mentor Mentor on the Lake Mentor Concord Fairport Harbor Painesville Perry Wickliffe Willoughby Hills Kirtland Waite Hill Willoughby Willoughby Hills Eastlake Lakeline Timberlake Willoughby Willowick Willoughby Eastlake Willoughby Geauga County ZIP Code City Auburn Township Bainbridge Township Chagrin Falls Chardon Concord Township Chesterland Montville Parkman Novelty Novelty Thompson Ashtabula County ZIP Code City Geneva 2

5 Underwriting guidelines Aetna Savings Plus Plans n Underwriting guidelines for the Savings Plus plans follow the same guidelines as the Ohio Small Group Standard portfolio. n Can be offered as a triple option next to a Standard plan in the portfolio. n Cannot be offered to employees out of state (OOS) or outside one of the specified counties/zip codes. n Eligible employees must reside in the Savings Plus area (see map opposite page): Lake Geauga Cuyahoga Ashtabula MULTI-OPTION OFFERINGS Greater employee choice Employers can offer any 3 of the 17 available standard plan designs, including Savings Plus plans. Flexibility and affordability Employers can create a customized benefits package from any of our plan types and plan designs. Aetna offers a variety of plans at different price points. Employers may designate a level of contribution that meets their budget. Total freedom Aetna offers 17 plan choices that range in price and benefits to help meet each individual employee s needs, whether they are lower premiums or lower out-of-pocket costs at the time services are received. Easy administration Setting up this program is simple: 1. The employer chooses up to 3 plans to offer on the Employer Application. 2. The employer chooses how much to contribute. 3. Each employee chooses the plan that s right for him or her. Multi-Option Offerings Target audience Plan choices Minimum participation 1 4 enrolled employees 5 50 enrolled employees Employer contribution Every small business with 5+ enrolled employees Up to 3 of the 17 available plans Choice of one plan Choice of up to 3 plans, minimum of 1 employee in each plan n 50% of employee-only premium or a minimum defined contribution of $120 per employee n The employer cannot fund the deductible in excess of 50% annually, whether through an HRA, HSA or any other funding arrangement n Coverage can be denied based on inadequate or excess contributions Rating options 1 4 enrolled employees Tabular 5 50 enrolled employees Option of tabular or composite 3

6 Aetna Small Group Medical Plans: Ohio Savings Plus Plan Options* Member Benefits Plan Options OH Savings Plus OAMC $ % Level 1: Savings Plus Designated Providers* Maximum Savings Level 2: Non-Designated Network Providers* Standard Savings Level 3: Out-of-Network Providers** PCP Referrals Required No No No Plan Coinsurance (Applies to most services) Calendar-Year Deductible (Level 1 accumulates separately from Levels 2 and 3 combined) Calendar-Year Out-of-Pocket Maximum (Includes deductible; excludes copayments and member coinsurance payments for DME; Level 1 accumulates separately from Levels 2 and 3 combined) $1,000 Individual $3,000 Family $4,000 Individual $12,000 Family $7,500 Individual $22,500 Family $15,000 Individual $45,000 Family Lifetime Maximum Benefit Unlimited Primary Physician Office Visit $30 copay, deductible waived 50% 50% Specialist Office Visit $50 copay, deductible waived 50% 50% Outpatient Lab $50 copay, deductible waived 50% 50% Outpatient X-ray $50 copay, deductible waived 50% 50% Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET scans; precertification required) Well Baby and Child Exams/Adult Physical Exams/Immunizations/Routine GYN Exams/ Routine Mammograms (Age/frequency schedules apply) Routine Eye Exam (One exam per 24 months; Levels 1, 2 and 3 combined) $0 copay, deductible waived $0 copay, deductible waived 50% $0 copay, deductible waived $0 copay, deductible waived 50% Inpatient Hospital Outpatient Surgery Emergency Room (Copay waived if admitted) $200 copay, deductible waived Urgent Care $50 copay, deductible waived 50% 50% Chiropractic (Limited to 12 visits per calendar year; Levels 1, 2 and 3 combined) Outpatient Physical/Occupational Therapy/ Speech Therapy (40 visits per calendar year; Levels 1, 2 and 3 combined) Prescription Drugs (Retail: per 30-day supply; mail order: two-and-a-half times retail copay; 31- to 90-day supply; includes insulin) $50 copay, deductible waived 50% 50% $50 copay, deductible waived 50% 50% $15/$35/$60/$150 70% after $15/$35/$60/$ Day Rx Transition of Coverage Included Included (TOC) with Prior Certification *** Easily locate provider information online Go to designates Savings Plus providers. * Managed Choice POS Open Access (OAMC) network providers. See page 7 for footnotes. 4

7 Aetna Small Group Medical Plans: Ohio Savings Plus Plan Options* Member Benefits Plan Options OH Savings Plus OAMC $ % Level 1: Savings Plus Designated Providers* Maximum Savings Level 2: Non-Designated Network Providers* Standard Savings Level 3: Out-of-Network Providers** PCP Referrals Required No No No Plan Coinsurance (Applies to most services) Calendar-Year Deductible (Level 1 accumulates separately from Levels 2 and 3 combined) Calendar-Year Out-of-Pocket Maximum (Includes deductible; excludes copayments and member coinsurance payments for DME; Level 1 accumulates separately from Levels 2 and 3 combined) $2,500 Individual $7,500 Family $5,000 Individual $15,000 Family $10,000 Individual $30,000 Family $20,000 Individual $60,000 Family Lifetime Maximum Benefit Unlimited Primary Physician Office Visit $30 copay, deductible waived 50% 50% Specialist Office Visit $50 copay, deductible waived 50% 50% Outpatient Lab $50 copay, deductible waived 50% 50% Outpatient X-ray $50 copay, deductible waived 50% 50% Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET scans; precertification required) Well Baby and Child Exams/Adult Physical Exams/Immunizations/Routine GYN Exams/ Routine Mammograms (Age/frequency schedules apply) Routine Eye Exam (One exam per 24 months; Levels 1, 2 and 3 combined) $0 copay, deductible waived $0 copay, deductible waived 50% $0 copay, deductible waived $0 copay, deductible waived 50% Inpatient Hospital Outpatient Surgery Emergency Room (Copay waived if admitted) $200 copay, deductible waived Urgent Care $50 copay, deductible waived 50% 50% Chiropractic (Limited to 12 visits per calendar year; Levels 1, 2 and 3 combined) Outpatient Physical/Occupational Therapy/ Speech Therapy (40 visits per calendar year; Levels 1, 2 and 3 combined) Prescription Drugs (Retail: per 30-day supply; mail order: two-and-a-half times retail copay; 31- to 90-day supply; includes insulin) $50 copay, deductible waived 50% 50% $50 copay, deductible waived 50% 50% $15/$35/$60/$150 70% after $15/$35/$60/$ Day Rx Transition of Coverage Included Included (TOC) with Prior Certification *** Easily locate provider information online Go to designates Savings Plus providers. * Managed Choice POS Open Access (OAMC) network providers. See page 7 for footnotes. 5

8 Aetna Small Group Medical Plans: Ohio Savings Plus Plan Options* Member Benefits Plan Options OH Savings Plus OAMC $ % Level 1: Savings Plus Designated Providers* Maximum Savings Level 2: Non-Designated Network Providers* Standard Savings Level 3: Out-of-Network Providers** PCP Referrals Required No No No Plan Coinsurance (Applies to most services) Calendar-Year Deductible (Level 1 accumulates separately from Levels 2 and 3 combined) Calendar-Year Out-of-Pocket Maximum (Includes deductible; excludes copayments and member coinsurance payments for DME; Level 1 accumulates separately from Levels 2 and 3 combined) $4,000 Individual $12,000 Family $7,000 Individual $21,000 Family $10,000 Individual $30,000 Family $20,000 Individual $60,000 Family Lifetime Maximum Benefit Unlimited Primary Physician Office Visit Specialist Office Visit Outpatient Lab Outpatient X-ray Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET scans; precertification required) Well Baby and Child Exams/Adult Physical Exams/Immunizations/Routine GYN Exams/ Routine Mammograms (Age/frequency schedules apply) Routine Eye Exam (One exam per 24 months; Levels 1, 2 and 3 combined) $0 copay, deductible waived $0 copay, deductible waived 50% $0 copay, deductible waived $0 copay, deductible waived 50% Inpatient Hospital Outpatient Surgery Emergency Room (Copay waived if admitted) 80% Urgent Care Chiropractic (Limited to 12 visits per calendar year; Levels 1, 2 and 3 combined) Outpatient Physical/Occupational Therapy/ Speech Therapy (40 visits per calendar year; Levels 1, 2 and 3 combined) Prescription Drugs (Retail: per 30-day supply; mail order: two-and-a-half times retail copay; 31- to 90-day supply; includes insulin) $15/$35/$60/$150 70% after $15/$35/$60/$ Day Rx Transition of Coverage Included Included (TOC) with Prior Certification *** Easily locate provider information online Go to designates Savings Plus providers. * Managed Choice POS Open Access (OAMC) network providers. See page 7 for footnotes. 6

9 Footnotes This is a partial description of the benefits available; for more information, refer to the specific plan design summary. The dollar amount copayments indicate what the member is required to pay and the percentage coinsurance indicates what Aetna is required to pay. The deductible applies to all medical benefits unless otherwise stated. * Managed Choice POS Open Access (OAMC) network providers. Easily locate Savings Plus Designated providers online. Go to Aetna DocFind: In the left column, scroll down to Other Directories. Select Savings Plus Ohio. ** We cover the cost of services based on whether doctors are in network or out of network. We want to help you understand how much Aetna pays for your out-of-network care. At the same time, we want to make it clear how much more you will need to pay for this out-of-network care. You may choose a provider (doctor or hospital) in our network, or you may choose to visit an out-of-network provider. If you choose a doctor who is out of network, your Aetna health plan may pay some of that doctor s bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital. When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the recognized or allowed amount. When you choose outof-network care, Aetna recognizes an amount based on what Medicare pays for these services. The government sets the Medicare rate. Your doctor sets his or her own rate to charge you. It may be higher sometimes much higher than what your Aetna plan recognizes. Your doctor may bill you for the dollar amount that Aetna doesn t recognize. You must also pay any coinsurance and deductibles under your plan. No dollar amount above the recognized charge counts toward your deductible or out-of-pocket maximums. To learn more about how we pay out-of-network benefits, visit and type how Aetna pays into the search box. You can avoid these extra costs by getting your care from Aetna s broad network of health care providers. Go to and click on Find a Doctor on the left side of the page. If you are already a member, sign on to your Aetna Navigator member site. This applies when you choose to get care out of network. When you have no choice (for example, an emergency room visit or other emergency services), we will pay the bill as if you got care in network. You pay cost sharing and deductibles for your in-network level of benefits, and you should contact Aetna if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your cost sharing and deductibles. *** Transition of Coverage for Prior Authorization helps members of new groups to transition to Aetna by providing a 90-calendar-day opportunity, beginning on the group s initial effective date, during which time prior authorization requirements will not apply to certain drugs. Once the 90 calendar days have expired, prior authorization edits will apply to all drugs requiring prior authorization as listed in the formulary guide. Members who have claims paid for a drug requiring prior authorization during the Transition of Coverage period may continue to receive this drug after the 90 calendar days and will not be required to obtain a prior authorization. Note: For a summary list of Limitations and Exclusions, refer to page 8. Some benefits are subject to limitations or visit maximums. Members or providers may be required to precertify or obtain prior approval for certain services, such as non-emergency hospital care. 7

10 Limitations and exclusions These plans do not cover all health care expenses and include exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, the plan documents may contain exceptions to this list based on state mandates or the plan design purchased. Medical limitations and exclusions n All medical or hospital services not specifically covered in, or which are limited to or excluded in, the plan documents n Charges related to any eye surgery mainly to correct refractive errors n Cosmetic surgery, including breast reduction n Custodial care n Dental care and X-rays n Donor egg retrieval n Experimental and investigational procedures n Hearing aids n Immunizations for travel or work n Infertility services, including, but not limited to, artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in the plan documents n Nonmedically necessary services or supplies n Orthotics n Over-the-counter medications and supplies n Reversal of sterilization n Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies or counseling and prescription drugs n Special-duty nursing n Weight-control services, including surgical procedures, medical treatments, weight-control/-loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including morbid obesity or for the purpose of weight reduction, regardless of the existence of comorbid conditions Pre-existing conditions exclusion provision These plans impose a pre-existing conditions exclusion, which may be waived in some circumstances (that is, creditable coverage) and may not be applicable to you. A pre-existing conditions exclusion means that if you have a medical condition before coming to our plan, you might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis or treatment was recommended or received or for which the individual took prescribed drugs within six months. Pre-existing conditions exclusion provisions are waived for any individual under the age of 19. Generally, this period ends the day before your coverage becomes effective. However, if you were in a waiting period for coverage, the six-month period ends on the day before the waiting period begins. The exclusion period, if applicable, may last up to 12 months from your first day of coverage, or if you were in a waiting period, from the first day of your waiting period. If you had prior creditable coverage within 90 days immediately before the date you enrolled under this plan, then the pre-existing conditions exclusion in your plan, if any, will be waived. If you had no prior coverage within the 90 days prior to your enrollment date (either because you had no prior coverage or because there was more than a 90-day gap from the date your prior coverage terminated to your enrollment date), we will apply your plan s pre-existing conditions exclusion. In order to reduce or possibly eliminate your exclusion period based on your creditable coverage, you should provide us a copy of any Certificates of Creditable Coverage you may have. Please contact your Aetna Member Services representative at AETNA if you need assistance in obtaining a Certificate of Creditable Coverage from your prior carrier or if you have any questions on the information noted above. The pre-existing conditions exclusion does not apply to pregnancy nor to a child who is enrolled in the plan within 31 days after birth, adoption or placement for adoption. Note: For late enrollees, coverage will be delayed until the plan s next open enrollment; the pre-existing conditions exclusion will be applied from the individual s effective date of coverage. 8

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12 Contact us For more information regarding the Aetna Savings Plus Plans for Northeast Ohio, please contact your Aetna Small Group account executive or our Broker Services Team toll-free at Aetna Avenue Your Destination for Small Business Solutions This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits may vary by location. Health benefits and insurance plans contain exclusions and limitations. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Plan features and availability may vary by location and group size. Plan For Your Health is a public education program from Aetna and The Financial Planning Association. Providers are independent contractors and not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features are subject to change. 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. Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a licensed pharmacy subsidiary of Aetna Inc. that operates through mail order. 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 OH A (8/11)