Aetna Open Choice PPO

Transcription

1 Aetna Open Choice PPO The Aetna PPO has an in-network benefit level and an out-of-network benefit level. Each time you seek care, you can choose between two levels of coverage: Preferred care provided through Aetna's extensive network of participating providers Non-preferred care provided through a provider who is outside of the network (and you are responsible for precertification When you receive care in-network: No referrals are needed You pay a copay for office visits, and most services, after deductible You have coverage for routine physicals and immunizations, as well as routine eye and hearing exams, all with a copay There are no reasonable and customary limitations Emergency coverage anytime, anywhere There are no claim forms With the Open Choice PPO plan, you ll have open access to any provider-including specialists-without a referral. Whether you re at home or away, open access means you have the freedom to go directly to the provider of your choice with no referrals necessary. Your benefit level will be determined according to your use of a participating or nonparticipating provider. Aetna Open Choice PPO is designed to help you and your family obtain health care at a reasonable cost. It is very simple to use. The decision regarding which health care provider to see is an open one each time you need to see a provider. However, you ll save money when you use providers who participate in the PPO network because you get higher, preferred benefit levels. If you decide to see a provider who is not participating in the PPO network, you will receive the plan s non-preferred benefit level. Simply present your ID card when seeking care through a participating provider. The provider will submit the claim to Aetna. Aetna will remit an Explanation of Benefits (EOB) to both you and the provider that will show your coinsurance and deductible responsibility. Choosing a Preferred Provider The provider directory is a good place to start. Your physicians may already participate with Aetna. You can also use DocFind Aetna s online provider directory to locate participating physicians based on geographical location, medical specialty and hospital affiliation. Make Your Choice with Confidence From the prestigious university hospital to the local family doctor, the Aetna PPO plan offers you access to a wide range of preferred providers who must meet our credentialing standards. When a physician asks to join Aetna s network, the physician s licenses, education and work history are reviewed. In addition, a committee of practicing physicians, who also care for Aetna members, reviews information about the physician and the office. And then Aetna routinely reviews his/her credentials to make certain they continue to meet Aetna s standards.

2 Eligibility You are eligible to participate in Aetna's PPO plan as of the day your employment begins if you are a regular full-time staff member (appointed at least 35 hours per week for not less than six months) of the endowed colleges and units a member of the faculty or academic staff of the endowed colleges (appointed at least one full semester at fulltime) a regular part-time staff member of the endowed colleges and units (appointed at least hours per week) who will be appointed for at least six months; or for academic teaching staff, appointed at least one semester at half time. a temporary staff member appointed initially for six months or longer; if the initial appointment (under six months) is extended past six months with no break in service, the effective date of coverage is based on the date the appointment is extended a postdoctoral fellow or visiting fellow without salary in a contract college division of Cornell If you are represented by a bargaining unit, your health care benefits are subject to the provisions of your particular bargaining agreement. Please refer to your labor agreement for details on participation. Who Is Eligible for Coverage? Generally you, your spouse or domestic partner and unmarried dependent children under age 19 are eligible for coverage. Dependent children include biological children, adopted children, and any other child you claim on your federal tax return who lives with you in a parent-child relationship. Coverage for unmarried dependent children may be extended to age 25 while they are full-time students. (Full-time is defined as 12 or more credit hours.) Coverage for mental or physically incapacitated children may also be continued, provided the disabling condition occurs while the child is a covered dependent, for as long as the dependent remains incapacitated. A domestic partnership is defined as two individuals of the same or opposite gender who live together in a long-term relationship of indefinite duration, with an exclusive mutual commitment in which the partners agree to be jointly responsible for each other's common welfare and to share financial obligations. If you wish to enroll your domestic partner and/or partner's eligible child(ren), you and your partner need to sign and return a Statement of Domestic Partnership form to Benefit Services, 130 Day Hall. Imputed Income Assessed on Domestic Partners The value of the health benefits your domestic partner receives is viewed as taxable income based on the Internal Revenue Code (IRC). Domestic partners do not meet the IRS's definition of a dependent. When the employer provides a benefit to someone other than a dependent (as defined by the IRC), the value of the benefit provided must be calculated into the gross income of the employee for tax purposes. Faculty and staff who cover a domestic partner should be aware that this may increase their federal and state taxes. The imputed income is the total amount Cornell contributes toward coverage, less the amount Cornell contributes for single coverage. The value is added in to your gross income biweekly or semi-monthly. The tax implications vary by individual and you may need to seek the advice of your tax advisor. If you are currently enrolled in individual plus child(ren) coverage and you are adding your domestic partner to your coverage, your imputed income is calculated on the value of the university's contribution for single coverage. Your additional contribution for providing benefit coverage to your domestic partner is the same as that charged for a spouse. These amounts are deducted from your pay check on an after-tax basis. See the Endowed Domestic Partner Questions & Answers for information on imputed income. Your additional contribution for providing benefit coverage to your domestic partner is the same as that charged for a spouse. These amounts are deducted from your pay check on an after-tax basis. Types of Coverage Available: individual coverage: covers the faculty or staff member only; individual plus child(ren) coverage: covers the faculty or staff member and his/her child or children; individual plus spouse/domestic partner and child(ren) coverage: covers the faculty or staff member, his/her spouse or domestic partner, and their child or children; dual eligibility. 2

3 Dual eligibility is a category available to an endowed staff or faculty member with dependent children whose spouse or domestic partner is also a benefits-eligible staff or faculty member in an endowed unit of Cornell University. Only one employee enrolls for coverage and that employee covers all dependents, including the working spouse or domestic partner. If you are covered within the dual-eligibility category, you must be sure to notify Benefit Services if you or your spouse or domestic partner leave the employment of an endowed unit at Cornell. It is the responsibility of the employee to sign up for the dual eligibility rate. It is not possible for dual-eligibility employees to cover each other or to both cover dependent children within the endowed health care program. Enrollment The majority of benefits-eligible faculty and staff can enroll on line in benefit plans. Group meetings are also an option and are designed to explain the benefits available to university employees. Each faculty and staff member are given enrollment materials to complete, which includes enrollment in the health care program. You have 60 days to enroll for health care coverage by completing the enrollment materials and returning them to Benefit Services. You will have the opportunity to change your coverage during the fall annual enrollment for coverage effective the following January 1. Identification Cards. In approximately 14 days after you initially enroll, you should receive your health care identification card at your home address. Members will receive two ID cards listing their covered family members. You need to show it to your health care provider so that your claims can be properly handled. If you need additional cards, call Aetna s Member Services at (877) Coverage Begins Coverage starts for you when you begin employment, provided you are actively at work on that date. If you are disabled, or not actively at work on the date your coverage would be effective, your coverage begins after one complete day of active employment. Late Enrollment A faculty or staff member who initially waives coverage and wishes to enroll at a later date must wait until the annual enrollment in the fall to enroll for coverage effective the following January 1. The exception to this would be if the faculty or staff member had a family status change. Coverage Changes: Annual Enrollment All eligible faculty and staff (including those who previously waived coverage) have the opportunity to enroll once a year during the annual enrollment period. Each employee receives a packet of information at his or her home address. New coverage selected during the annual enrollment period is effective the following January as long as no one seeking coverage is hospitalized on that date. If a member of your family is hospitalized, coverage is delayed for that individual until he or she is released from the hospital. Family Status Changes It also possible to add or drop coverage for yourself or your family members ONLY if you experience one of the following family status changes and contact Benefit Services within 60 days of any of the following events: marriage or divorce birth or adoption (effective date placed for adoption) of a child death of a spouse/domestic partner or child termination or commencement of your (or your spouse/domestic partner's) employment your spouse/domestic involuntarily loses eligibility for employer-provided health coverage or your spouse/domestic partner involuntarily gains coverage (e.g., your spouse/domestic partner's employer changes health coverage significantly or the eligibility requirements of the employer-provided health plan change to allow your spouse/domestic partner to be eligible for coverage) qualifying for Medicare by you or your dependents family medical leave 3

4 Section 125, the Internal Revenue Code and related regulations which govern certain aspects of the plan's operation prohibit employees from making a change in coverage during the year unless one of the family status changes outlined above occurs. Of course, you can always change your coverage election during the annual enrollment period each November. Changes made during the annual enrollment period are effective January 1 of the following year. Our plan is administered in this manner to comply with IRS regulations. To add or drop coverage you need to complete an Open Choice enrollment form and return it to Benefit Services within 60 days of the status change. Changes not made within 60 days must wait until the annual enrollment period. Adding Coverage for Newborns If you have single coverage at the time your child is born or adopted, you have 60 days to contact Benefit Services to add the child to your medical coverage and to change to a new coverage tier (individual plus spouse/domestic partner, individual plus child(ren) or individual plus spouse/domestic partner plus child(ren) (complete a "Cornell Endowed Aetna PPO form). Aetna will produce new ID cards reflecting family coverage in about 14 days. A faculty or staff member with individual plus spouse/domestic partner, individual plus child(ren) or individual plus spouse/domestic partner plus child(ren) coverage must also contact Benefit Services and complete a new Cornell Endowed Aetna PPO form indicating "change" to add a new child (within 60 days). Failure to add the newborn or adopted child within 60 days of birth or adoption will result in not being able to add the child to the Plan until the annual open enrollment period in November for coverage effective the following January 1. Cost of Coverage In most cases, your share of the cost of health insurance coverage is deducted on a pre-tax basis directly from your paycheck. The cost of coverage depends on the coverage type you enroll in (individual, individual plus spouse/domestic partner, individual plus child(ren) or individual plus spouse/domestic partner plus child(ren)). In certain situations faculty and staff pay the full cost of coverage (e.g., leave of absence without pay, contract college postdoctoral fellows). The cost, including the annual deductible and out-of-pocket maximum, is subject to change annually and depends in part on the claims experience of Cornell's faculty and staff and their families during the preceding year. Please refer to the endowed health rate chart for additional information. *Note: the dual spouse category is available to an endowed staff or faculty member with dependent child(ren) whose spouse or domestic partner is also a benefits-eligible staff or faculty member in an endowed unit or Cornell University. Health Coverage Regardless of whether you use a preferred or non-preferred provider, the Aetna PPO plan covers the same wide range of medically necessary services*: Physician office visits Hearing aids Hospitalization and surgery Diagnostic testing Emergency care Home health care Maternity and newborn care Durable medical equipment While Aetna PPO's network is extensive, there may be special circumstances when you need specialty care that is not available through a preferred provider. In such cases, your use of a non-preferred provider is reimbursed at 90% after the in-network deductible. If you have questions concerning this provision, call Aetna s Member Services at (877) Emergencies Medical emergencies are those whose symptoms could be perceived as life-threatening or as causing serious harm if not treated quickly. Emergencies are covered at the higher benefit level whether you use a preferred or non-preferred provider (paid at 90% after the deductible). However, non-emergency use of the emergency room is reimbursed at 50% after the deductible. 4

5 Deductible The deductible is the amount you will have to pay before the plan reimburses in a calendar year for eligible medical expenses. The deductibles between the preferred and non-preferred benefits cross apply. Out-of-pocket Maximum The out-of-pocket maximum is the most you will have to pay for eligible medical expenses in a calendar year. When your share of expenses (excluding copays) are reached, the plan pays $100% of eligible covered expenses for the rest of the calendar year for in-network expenses. The following charges are not eligible to be credited toward the out-of-pocket maximum: amounts you are penalized for failure to comply with the program's precertification requirements; copays, amounts above and beyond reasonable and customary charges; mental health and substance abuse benefits and items not covered under the plan. Reasonable and Customary (R&C) In joining Aetna s network, physicians and health care facilities have agreed to charge negotiated rates. They cannot balance bill. It is standard practice for insurance companies to set, within defined geographic areas, reasonable and customary limits for common medical procedures. Aetna obtains R&C information from the Health Insurance Association of America. If you seek care out-of-network, Aetna will reimburse at 80% after the deductible subject to R&C. You may actually pay more than the individual out-of-pocket maximum. For mental health and substance abuse benefits, please refer to the Endowed Health Plans Comparison Chart concerning R&C information. Centers of Excellence Program Aetna s Centers of Excellence Program recognizes how difficult it is for a patient/family who may be facing a complex medical procedure or transplant. As a patient needs arise for highly specialized procedures, certified case managers will work with the patient, family and physician in determining the most appropriate facility and physician as well as providing continuity of care. Aetna will provide access to care through their expanding network of healthcare providers identified as providing successful clinical outcomes. Sabbaticals and When You Travel If you need non-emergency care away from home for a covered service, simply contact Aetna s Member Services to locate a preferred provider in the area you are visiting or access Aetna s provider directory. If you receive care from a nonpreferred provider and Aetna did have participating providers, you will be covered at 80% after the preferred deductible. Non-emergency care received outside of the United States will be reimbursed at 90% after satisfaction of the preferred (in-network) deductible. Coverage for Out-of-Area Dependents Your dependent child(ren) who do not reside with you, but who meet the eligibility requirements, can be enrolled in the PPO plan which is available in 47 states. You can contact Aetna s Member Services at (877) or check Aetna s provider directory to locate a preferred provider in the area where they reside. If they receive care from a non-preferred provider, they will be covered at 80% after the preferred deductible. Three-Tier Prescription Drug Plan Administered by Express Scripts Prescription drugs are covered through Express Scripts Behavioral Health Benefits Aetna member s behavioral health care is managed and administered by Aetna Behavioral Health. To receive the in-network benefit level, you must go to a participating provider. All care must meet Aetna behavioral health criteria for medical necessity. Inpatient behavioral health: If you see a participating Aetna provider, precertification is not required. If you see a non-participating provider, it is your responsibility to precertify. Stays not precertified are subject to a $400 penalty. Outpatient behavioral health: Members are not required to precertify outpatient care. Some intensive outpatient services do require precertification if the member is going out of network. To find a participating Aetna behavioral health provider, call Aetna at (877)

6 Coordination of Benefits (COB) The PPO Plan has a maintenance of benefits provision that provides payment up to the normal reimbursement level under the PPO Plan. When you or your covered family member has other group health care benefits available or if payment is made under a "no-fault" auto insurance policy, the maintenance of benefits provision takes effect. This means that the combined payment from both sources will not exceed the amount the PPO Plan pays when there is no coordination with another plan. Under most circumstances, your combined reimbursement will total 90% and you will still have responsibility for the copay until your out-of-pocket maximum has been reached. The prescription drug plan is a card program and is excluded from the maintenance of benefits provision. Coordination with No-fault Auto Insurance In the case of a payment under the New York's "no-fault" auto insurance, the first $50,000 is paid by New York State. Any charges remaining are reimbursed, after deductible, at 90% until the out-of-pocket maximum is reached. Subrogation Provision This provision prevents faculty/staff and covered family members from being reimbursed for medical bills both from PPO Plan and from a third party insurance company, in effect receiving a duplicate reimbursement. For example, a subrogation right might exist when the PPO Plan has paid medical expenses for injuries a faculty/staff member suffered while helping a neighbor repair his or her roof. If the injured faculty/staff member receives a payment from a third party for medical expenses incurred as a result of the fall (for example, the neighbor's homeowner's policy), the PPO Plan is entitled to be reimbursed for all or part of the costs covered through Cornell's health care plan. In order to review possible subrogation situations, claims will be pended by PPO Plan until details are received explaining the nature of the accident. Order and Priority of Benefits Under the COB provisions, you file your claim with the primary carrier first and then send copies of the same bills and your Explanation of Benefits to the secondary carrier for consideration. A plan without coordination of benefits always pays first. If all plans have COB provisions, the order of payment is determined by the following: the plan covering the person directly, rather than as a dependent, pays its benefits first in the case of dependent children, the plan of the parent whose birthday occurs first in the calendar year will pay benefits first in the case of a divorce or separation, the plan that covers the parent with financial responsibility for health care expenses, a qualified medical support order (QMCSO), or custody pays benefits first the plan that has covered the person for the longer period of time shall be primary except if a retiree or laid-off worker goes to work for another employer. The plan of the current employer will pay benefits before the plan covering the individual (and family) as a retiree or laid-off employee. If you are covered by more than one group health insurance plan and need assistance determining which plan should receive your bills first, call Aetna s Member Services at (877) Continuation and Termination of Benefits: When Coverage Ends Unless you provide notification that you would like to continue health coverage, your current coverage will end at the end of the pay period in which you receive your last paycheck. Continuing Coverage Faculty and staff and/or their eligible family members who are covered under the PPO Plan may continue medical coverage should one of the following situations occur (provided coverage is in effect on the date the event occurs): family medical leave death or total disability divorce or legal separation layoff of a covered employee retirement prior to eligibility for Medicare veterans called to active duty 6

7 Family Medical Leave Family Medical Leave entitles eligible faculty and staff to unpaid time away from work, up to total of 12 weeks during the fiscal year (July 1 - June 30). This is in accordance with the Family and Medical Leave Act (FMLA) of Contact Workers' Compensation/Disability Services or review the Human Resource Policy 6.9 Time Away from Work and related guidelines for full details about FMLA. You may continue your existing health insurance coverage during an unpaid FML, (no use of accrued sick or vacation) and you will be billed by PayFlex. If you decide to terminate your health insurance coverage either at the start or during your FML, when you return from the leave, you have the right to have your health insurance reinstated, within 60 days, on the same terms as prior to the leave. You may continue your existing health insurance coverage during FML provided you continue to pay for the employee share of the premiums. If you are taking an unpaid FML, (no use of accrued sick or vacation) you will be billed by PayFlex. If you decide to terminate your health insurance coverage either at the start or during the FML, when you return from the leave, you have the right to have your health insurance reinstated on the same terms as prior to the leave. Spouse, Domestic Partner and Dependent Coverage After Your Death In the event that a covered employee or retiree dies, the surviving spouse/domestic partner and any eligible covered dependent children may continue the health care plan until the surviving spouse remarries, the domestic partner indicates that the exclusiveness of the former relationship has been made void, and/or the dependent children no longer qualify under the program definitions. The university contribution will continue and the surviving spouse or domestic partner will be billed for any required employee or retiree contribution. Short Term Disability A covered staff member who qualifies for short term disability benefits can continue the coverage in effect at the time the disability occurs until the disability ends. The university contribution will continue during the period of disability and the staff member will continue to have the health insurance premium deducted from the paycheck. Total Disability A covered facility or staff member who qualifies for long term disability benefits can continue the coverage in effect at the time the disability occurs until the period of disability ends. The university contribution will continue during the period of disability and the faculty or staff member will be billed for any required contribution. Worker's Compensation As a regular university faculty or staff member, you are eligible to continue certain benefits while you receive Worker's Compensation benefits. There is no change in your benefits as long as you continue to receive a Cornell paycheck. Normal health insurance deductions will be taken out of each check. However, once you are no longer receiving a paycheck from Cornell, endowed faculty and staff are billed on a quarterly basis for the employee cost of health insurance. The university contribution will continue during the period of disability and the faculty or staff member will be billed for any required contribution. Divorce or Legal Separation If you or your spouse/domestic partner decide to legally separate, you (and any eligible dependents) can continue coverage. However, your ex-spouse will no longer be eligible to continue coverage under your plan. You are required to complete an enrollment form within 60 days of the divorce/legal separation and include proof. By taking this action, your ex-spouse will receive COBRA materials from Aetna and will be able to continue coverage within 60 days of the event or legal separation. The ex-spouse will be billed monthly, in advance, for up to 36 months. Qualified Medical Child Support Order As a general rule, your plan benefits may not be assigned to another person. However, an exception exists in the case of a "qualified medical child support order". A qualified medical child support order is a court-ordered judgment, decree, order or property settlement agreement in connection with state domestic relations law that either: creates or extends the rights of an "alternate recipient" to participate in a group health plan, including this plan; or enforces certain laws relating to medical child support. An "alternate recipient" is any child of a participant who is recognized by a medical child support order as having a right to enrollment under a participant's group health plan. A medical child support order must satisfy certain specific conditions to be qualified. The plan administrator will notify you if he or she receives a medical child support order that applies to you. 7

8 You will also be notified of the plan's procedures for determining whether the medical child support order is qualified. The cost of our coverage depends on whether or not you elect individual or family coverage. Coverage During Layoff Faculty or staff members who are no longer working because of a layoff or reduction in work force will be able to continue this plan under COBRA. Aetna is the COBRA administrator and will send you COBRA materials to complete in order to continue coverage. Completion of a COBRA application is required. The University contribution toward the cost of health coverage will continue for up to 12 months. If coverage is elected, you will be billed for the employee portion of the cost of your health plan. At the end of the 12 months, you will be billed the normal COBRA contribution rate for the remainder of your COBRA eligibility period. Position Leave Employee's existing health insurance coverage will be maintained during the leave period provided they continue to pay both their share and the university's share of premiums (full cost). University Leave Staff members who voluntarily resign their positions and are granted a University leave are eligible to continue this plan under COBRA. Aetna will send you the COBRA materials You will need to complete a COBRA enrollment form within 60 days of the University leave date or the date of Aetna's notification to continue health coverage at the full COBRA cost. Temporary Coverage Under COBRA COBRA (Consolidated Omnibus Budget Reconciliation Act) is federal legislation which requires that employers make continuing health coverage available to employees who are no longer eligible for coverage based on the following situations: termination of employment for reasons other than gross misconduct reduction in work hours resulting in loss of eligibility for health coverage a dependent child no longer meets the program's eligibility requirements. The duration of COBRA coverage depends on the particular event that causes you or an eligible member of your family to lose coverage. 18-Month COBRA Eligibility If your employment terminates, your work hours are reduced or you are on a leave of absence, you and your covered dependents have the opportunity to subscribe for continuation of health coverage at group rates, for up to 18 months. You will automatically be notified of your eligibility to temporarily continue health coverage by Aetna.. If you do elect to continue COBRA coverage, Aetna will bill monthly, in advance, for the full cost of this coverage (plus an additional 2% administrative fee). 36-Month COBRA Eligibility If your dependent loses eligibility for health coverage because he/she no longer meets the health program's definition of an eligible dependent or if you are divorced and your ex-spouse wishes to continue prior coverage, it is your responsibility to remove the ineligible dependent from your health insurance coverage. This will insure that your coverage is both updated and you are paying the right premium for the correct coverage level. More importantly, it will insure Aetna (the COBRA Administrator for both Aetna and HealthNow) receives information that your dependent is no longer enrolled and will send COBRA continuation of health coverage materials. Your dependent will have 60 days from the date of Aetna's Notice to enroll in COBRA coverage. The cost of COBRA coverage will be billed monthly, in advance, for up to 36 months by Aetna's COBRA Direct Billing Unit. Failure to pay these charges within 30 days of the billing date will result in immediate termination of coverage. Sabbatical Leaves Coverage continues provided you continue to pay the required premium, which continues to be deducted from your paycheck. Coverage Upon Retirement Your coverage under the Cornell Health Care Program can be continue into retirement if you are at least age 55 when you retire and have at least 10 years of benefits-eligible service with Cornell University. Important: If you decide not to continue your health insurance at any time and cancel your coverage, you will not be able to re-enroll at a later date. 8

9 If you are not yet age 65 when you retire and are therefore, not eligible for Medicare, you have the opportunity to continue coverage under the health care program that is available to active employees. If you are covering a spouse/domestic partner under the Plan who is retired and age 65 or older, they must enroll in Medicare Parts A & B. This also applies if your spouse/domestic partner has been receiving Social Security Disability benefits and is eligible for Medicare. Upon attainment of age 65, you will automatically be transferred to Cornell's 80/20 Plan for Retirees. If you are 65 or older when you retire and are eligible for Medicare, you will receive coverage under the 80/20 Plan for Retirees. An employee who retires and has not met the eligibility requirements for retiree medical coverage may be eligible to continue coverage under the COBRA provisions. If you retire before you turn 65 and are not eligible for Medicare, you can continue coverage for up to 18 months or until you are eligible for Medicare (whichever occurs first). Your family members also have the opportunity to continue health coverage for a period not to exceed 36 months from the date you retire or become eligible for Medicare. Filing Medical Claims If you need help filing claims for services received out-of-network, or have questions you can call Aetna s Member Services at (877) and a Member Services Representative will be happy to help you. If your claim involves coordination of benefits with another insurance company, you must also include a copy of the explanation of benefits provided by the other company (including Medicare). Claims must be filed within 2 years from the date of service. Medical benefits for any covered individual may be assigned to the hospital, doctor or other health care provider. When benefits are assigned, payment will be made directly to the health care providers. Please note that this is a summary. Official benefits and conditions of coverage are contained in your contract. The complete terms of the programs are contained in the official plan document, which will govern in the case of discrepancy. 10/13 9