Aetna Medicare SM Plan (PPO) Offered by Aetna Life Insurance Company Annual Notice of Changes for 2016 You are currently enrolled as a member of Aetna Medicare Plan (PPO). Next year, there will be some changes to the plan s costs and benefits. This booklet tells about the changes. We are providing this information about your Medicare Advantage plan in accordance with requirements from the Centers for Medicare & Medicaid Services (CMS). Please review this information as background to help you decide what coverage to choose for 2016. Additional Resources This information is available for free in other languages. Please contact our Customer Service number at 1-866-282-0631 for additional information. (For TTY assistance please call 711). We re available 8 a.m. to 8 p.m. local time, Monday through Friday. Calls to these numbers are toll free. Customer Service also has free language interpreter services available for non-english speakers. Esta información está disponible en otros idiomas de manera gratuita. Si desea más información, comuníquese con Servicios al Cliente al 1-866-282-0631. (Los usuarios de TTY deben llamar al 711). Horario de atención: de 8 a.m. a 8 p.m., Lunes a Viernes. Las personas que no hablan inglés pueden solicitar el servicio gratuito de intérpretes a Servicios al Cliente. This document may be made available in other formats such as Braille, large print or other alternate formats. Please contact Customer Service for more information. About Aetna Medicare Plan (PPO) Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with State Medicaid programs. Enrollment in our plans depends on contract renewal. When this booklet says we, us, or our, it means Aetna Medicare. When it says plan or our plan, it means Aetna Medicare Plan (PPO). STRS_EGWP_CCP_L7_2016_Part_B_Only_PPO Part B Only PPO no Rx (Y2016) Form CMS 10260-ANOC/EOC OMB Approval 0938-1051 (Approved 03/2014)
Aetna Medicare SM Plan (PPO) Annual Notice of Changes for 2016 1 Think about Your Medicare Coverage for Next Year You can change your coverage during State Teacher s Retirement of Ohio s (STRS OHIO) open enrollment period each year. In addition, each fall, Medicare allows you to change your Medicare health and drug coverage during the Annual Enrollment Period. It s important to review your coverage now to make sure it will meet your needs next year. To decide what s best for you, compare this information with the benefits and costs of other Medicare health plans STRS Ohio may offer and other individual Medicare health plans available in your area, as well as the benefits and costs of Original Medicare. (It is important that you carefully consider your decision before dropping your STRS Ohio coverage. This is important because you may lose benefits you currently receive under STRS Ohio if you switch plans. Call STRS Ohio for information. See Section 3.2 for more information.) Important things to do: Check the changes to our benefits and costs to see if they affect you. Do the changes affect the services you use? It is important to review benefit and cost changes to make sure they will work for you next year. Look in Section 1.4 for information about benefit and cost changes for our plan. Check to see if your doctors and other providers will be in our network next year. Are your doctors in our network? What about the hospitals or other providers you use? Look in Section 1.3 for information about our Provider Directory. Think about your overall health care costs. How much will you spend out-of-pocket for the services and prescription drugs you use regularly? How much will you spend on your premium? How do the total costs compare to other Medicare coverage options? Think about whether you are happy with our plan. If you decide to stay with Aetna Medicare (PPO) plan: If you decide to stay with the same Aetna Medicare plan next year, STRS Ohio will give you instructions if there is any action you need to take to remain enrolled.
Aetna Medicare SM Plan (PPO) Annual Notice of Changes for 2016 2 If you decide to change plans: If you decide to leave your current Aetna Medicare plan for 2016, you have choices on how to receive your Medicare benefits. You can change your coverage during STRS Ohio s open enrollment period. STRS Ohio will tell you what other plan choices might be available to you under your group retiree coverage. You can switch to an individual Medicare health plan or to Original Medicare; however, this would mean dropping your group retiree coverage. Medicare s general annual election period for Medicare beneficiaries runs from October 15 through December 7 of 2015. Or, you may access plans in the individual marketplace at any time through a special enrollment period. Look in Section 3.2 to learn more about your choices. It is important that you carefully consider your decision before dropping your STRS Ohio coverage. This is important because you may lose benefits you currently receive under STRS Ohio if you switch plans. If you are not currently entitled to Medicare Part A, you are enrolled in our plan through a special eligibility waiver. If you leave your group retiree coverage and want to join another Medicare Advantage plan, you may have to get Medicare Part A and pay an additional monthly premium. Call STRS Ohio for information. Summary of Important Costs for 2016 The table below compares the 2015 costs and 2016 costs for our plan in several important areas. Please note this is only a summary of changes. It is important to read the rest of this Annual Notice of Changes and review the enclosed Evidence of Coverage to see if other benefit or cost changes affect you. Cost 2015 (this year) 2016 (next year) Deductible Network: $300 Combined In- and Out-of- Network Deductible: $500 Network: $150 Combined In- and Out-of- Network Deductible: $500 Maximum out-of-pocket amounts This is the most you will pay out-of-pocket for your covered medical services. (See Section 1.2 for details.) From network providers: $1,500 From network and out-ofnetwork providers combined: $2,000 From network providers: $1,500 From network and out-ofnetwork providers combined: $2,500
Aetna Medicare SM Plan (PPO) Annual Notice of Changes for 2016 3 Cost 2015 (this year) 2016 (next year) Doctor office visits Network: Primary care visits: You pay $15 copay per visit Network: Primary care visits: You pay $15 copay per visit Specialist visits: You pay $25 copay per visit Out-of-network: Primary care visits: You pay a $40 copay per visit Specialist visits: You pay $25 copay per visit Out-of-network: Primary care visits: You pay a $40 copay per visit Inpatient hospital stays Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor s order. The day before you are discharged is your last inpatient day. Specialist visits: You pay a $50 copay per visit Network: You pay 4% of the cost per stay Out-of-network: You pay 6% of the cost per stay Specialist visits: You pay a $55 copay per visit Network: You pay 4% of the cost per stay Out-of-network: You pay 8% of the cost per stay
Aetna Medicare SM Plan (PPO) Annual Notice of Changes for 2016 4 Annual Notice of Changes for 2016 Table of Contents Think about Your Medicare Coverage for Next Year... 1 Summary of Important Costs for 2016... 2 SECTION 1 Changes to Benefits and Costs for Next Year... 5 Section 1.1 Changes to the Monthly Premium (if applicable)... 5 Section 1.2 Changes to Your Maximum Out-of-Pocket Amounts... 5 Section 1.3 Changes to the Provider Network... 6 Section 1.4 Changes to Benefits and Costs for Medical Services... 6 SECTION 2 Other Changes... 13 SECTION 3 Deciding Which Plan to Choose... 13 Section 3.1 If You Want to Stay in Aetna Medicare Plan (PPO)... 13 Section 3.2 If You Want to Change Plans... 13 SECTION 4 Deadline for Changing Plans... 14 SECTION 5 Programs That Offer Free Counseling about Medicare... 15 SECTION 6 Programs That Help Pay for Prescription Drugs... 15 SECTION 7 Questions?... 16 Section 7.1 Getting Help from Aetna Medicare Plan (PPO)... 16 Section 7.2 Getting Help from Medicare... 17
Aetna Medicare SM Plan (PPO) Annual Notice of Changes for 2016 5 SECTION 1 Changes to Benefits and Costs for Next Year Section 1.1 Changes to the Monthly Premium (if applicable) Your coverage is provided through a contract with STRS Ohio. STRS Ohio will provide you with information about your plan premium (if applicable). (You must continue to pay your Medicare Part B premium.) Section 1.2 Changes to Your Maximum Out-of-Pocket Amounts To protect you, Medicare requires all health plans to limit how much you pay out-of-pocket during the year. These limits are called the maximum out-of-pocket amounts. Once you reach this amount, you pay nothing for covered Part A and Part B services for the rest of the year. Cost 2015 (this year) 2016 (next year) Network maximum out-of-pocket amount Your costs for covered medical services (such as copays, coinsurance and deductibles) from network providers count toward your network maximum out-of-pocket amount. Your plan premium (if applicable) does not count toward your maximum out-of-pocket amount. Combined maximum out-of-pocket amount Your costs for covered medical services (such as copays, coinsurance and deductibles) from network and out-of-network providers count toward your combined maximum out-of-pocket amount. Your plan premium (if applicable) does not count toward your maximum out-of-pocket amount. $1,500 $1,500 Once you have paid $1,500 out-of-pocket for covered medical services from network providers, you will pay nothing for your covered Part A and Part B services from network providers for the rest of the calendar year. $2,000 $2,500 Once you have paid $2,500 out-of-pocket for covered medical services, you will pay nothing for your covered Part A and Part B services from network or out-ofnetwork providers for the rest of the calendar year.
Aetna Medicare SM Plan (PPO) Annual Notice of Changes for 2016 6 Section 1.3 Changes to the Provider Network There are changes to our network of providers for next year. An updated Provider Directory is located on our website at http://www.aetnaretireeplans.com. You may also call Customer Service for updated provider information or to ask us to mail you a Provider Directory. Please review the 2016 Provider Directory to see if your providers (primary care provider, specialists, hospitals, etc.) are in our network. It is important that you know that we may make changes to the hospitals, doctors and specialists (providers) that are part of your plan during the year. There are a number of reasons why your provider might leave your plan but if your doctor or specialist does leave your plan you have certain rights and protections summarized below: Even though our network of providers may change during the year, Medicare requires that we furnish you with uninterrupted access to qualified doctors and specialists. When possible we will provide you with at least 30 days notice that your provider is leaving our plan so that you have time to select a new provider. We will assist you in selecting a new qualified provider to continue managing your health care needs. If you are undergoing medical treatment you have the right to request, and we will work with you to ensure, that the medically necessary treatment you are receiving is not interrupted. If you believe we have not furnished you with a qualified provider to replace your previous provider or that your care is not being appropriately managed you have the right to file an appeal of our decision. If you find out your doctor or specialist is leaving your plan please contact us so we can assist you in finding a new provider and managing your care. Section 1.4 Changes to Benefits and Costs for Medical Services We are changing our coverage for certain medical services next year. The information below describes these changes. For details about the coverage and costs for these services, see the 2016 Medical Benefits Chart (Schedule of Copayments/Coinsurance) included in this package. Cost 2015 (this year) 2016 (next year) First 3 pints of blood benefit Not included Included Yearly deductible Network: $300 Network: $150
Aetna Medicare SM Plan (PPO) Annual Notice of Changes for 2016 7 Cost 2015 (this year) 2016 (next year) Ambulance services Cardiac rehabilitation services Chiropractic services Complex imaging Compression stockings Combined In- and Out-of- Network Deductible: $500 Network: You pay 4% of the total cost per service Out-of-network: You pay 6% of the total cost per service Network: You pay a $25 copay per service Out-of-network: You pay a $50 copay per service Network: You pay 4% of the total cost of the visit Out-of-network: You pay 6% of the total cost of the visit Network: You pay 4% of the total cost of the service Out-of-network: You pay 6% of the total cost of the service Network: You pay 4% per item Out-of-network: You pay 6% per item Combined In- and Out-of- Network Deductible: $500 Network: You pay 4% of the total cost per service Out-of-network: You pay 8% of the total cost per service Network: You pay a $25 copay per service Out-of-network: You pay a $55 copay per service Network: You pay 4% of the total cost of the visit Out-of-network: You pay 8% of the total cost of the visit Network: You pay 4% of the total cost of the service Out-of-network: You pay 8% of the total cost of the service Network: You pay 4% per item Out-of-network: You pay 8% per item
Aetna Medicare SM Plan (PPO) Annual Notice of Changes for 2016 8 Cost 2015 (this year) 2016 (next year) Diagnostic procedures and tests Diagnostic radiology service Durable medical equipment and related supplies Home health agency care Inpatient dialysis Network: You pay 4% of the total cost per service Out-of-network: You pay 6% of the total cost per service Network: You pay 4% of the total cost of the service Out-of-network: You pay 6% of the total cost of the service Network: You pay 4% of the total cost of the equipment and related supplies Out-of-network: You pay 6% of the total cost of the equipment and related supplies Network: You pay a $0 copay per visit Out-of-network: You pay a $0 copay per visit Network: You pay 4% of the total cost of the visit Network: You pay 4% of the total cost per service Out-of-network: You pay 8% of the total cost per service Network: You pay 4% of the total cost of the service Out-of-network: You pay 8% of the total cost of the service Network: You pay 4% of the total cost of the equipment and related supplies Out-of-network: You pay 8% of the total cost of the equipment and related supplies Network: You pay a $0 copay per visit Out-of-network: You pay 8% of the total cost per visit Network: You pay 4% of the total cost of the visit Inpatient hospital care Out-of-network: You pay 6% of the total cost of the visit Network: You pay 4% of the total cost of the visit Out-of-network: You pay 8% of the total cost of the visit Network: You pay 4% of the total cost of the visit
Aetna Medicare SM Plan (PPO) Annual Notice of Changes for 2016 9 Cost 2015 (this year) 2016 (next year) Inpatient mental health care Out-of-network: You pay 6% of the total cost of the visit Network: You pay 4% of the total cost of the visit Out-of-network: You pay 8% of the total cost of the visit Network: You pay 4% of the total cost of the visit Medicare-covered dental services Medicare-covered hearing services Medicare-covered vision services Outpatient hospital services Out-of-network: You pay 6% of the total cost of the visit Network: You pay a $25 copay per service Out-of-network: You pay a $50 copay per service Network: You pay a $25 copay per service Out-of-network: You pay a $50 copay per service Network: You pay a $25 copay per service Out-of-network: You pay a $50 copay per service Network: You pay 4% of the total cost of the service Out-of-network: You pay 6% of the total cost of the service Out-of-network: You pay 8% of the total cost of the visit Network: You pay a $25 copay per service Out-of-network: You pay a $55 copay per service Network: You pay a $25 copay per service Out-of-network: You pay a $55 copay per service Network: You pay a $25 copay per service Out-of-network: You pay a $55 copay per service Network: You pay 4% of the total cost of the service Out-of-network: You pay 8% of the total cost of the service
Aetna Medicare SM Plan (PPO) Annual Notice of Changes for 2016 10 Cost 2015 (this year) 2016 (next year) Outpatient medical/surgical supplies Network: You pay a $15 copay for supplies received during a PCP visit You pay a $25 copay for supplies received from other network providers Out-of-network: You pay a $40 copay for supplies received during a PCP visit You pay $50 copay for supplies received from other network providers Network: You pay a $15 copay for supplies received during a PCP visit You pay a $25 copay for supplies received from other network providers Out-of-network: You pay a $40 copay for supplies received during a PCP visit You pay $55 copay for supplies received from other network providers Outpatient mental health care Outpatient rehabilitation services Network: You pay a $25 copay per service Out-of-network: You pay a $50 copay per service Network: You pay 4% of the total cost of the service Out-of-network: You pay 6% of the total cost of the service Network: You pay a $25 copay per service Out-of-network: You pay a $55 copay per service Network: You pay 4% of the total cost of the service Out-of-network: You pay 8% of the total cost of the service Outpatient substance abuse services Network: You pay a $25 copay per service Out-of-network: You pay a $50 copay per service Network: You pay a $25 copay per service Out-of-network: You pay a $55 copay per service
Aetna Medicare SM Plan (PPO) Annual Notice of Changes for 2016 11 Cost 2015 (this year) 2016 (next year) Outpatient surgery Partial hospitalization services Medicare-covered podiatry services Prosthetic devices and related supplies Network: You pay 4% of the total cost of the service Out-of-network: You pay 6% of the total cost of the service Network: You pay a $25 copay per service Out-of-network: You pay a $50 copay per service Network: You pay a $25 copay per visit Out-of-network: You pay a $50 copay per visit Network: You pay 4% of the total cost of the prosthetic devices and related supplies Out-of-network: You pay 6% of the total cost of the prosthetic devices and related supplies Network: You pay 4% of the total cost of the service Out-of-network: You pay 8% of the total cost of the service Network: You pay a $25 copay per service Out-of-network: You pay a $55 copay per service Network: You pay a $25 copay per visit Out-of-network: You pay a $55 copay per visit Network: You pay 4% of the total cost of the prosthetic devices and related supplies Out-of-network: You pay 8% of the total cost of the prosthetic devices and related supplies Pulmonary rehabilitation services Network: You pay a $25 copay per visit Out-of-network: You pay a $50 copay per visit Network: You pay a $25 copay per visit Out-of-network: You pay a $55 copay per visit
Aetna Medicare SM Plan (PPO) Annual Notice of Changes for 2016 12 Cost 2015 (this year) 2016 (next year) Skilled nursing facility (SNF) care Specialist visit Therapeutic radiology service Medicare covered routine X-ray Network: You pay $0 copay per day, days 1-100 Out-of-network: You pay $0 copay per day, days 1-100 Network: You pay a $25 copay per service Out-of-network: You pay a $50 copay per service Network: You pay 4% of the total cost of the service Out-of-network: You pay 6% of the total cost of the service Network: You pay 4% of the total cost of the service Out-of-network: You pay 6% of the total cost of the service Network: You pay $0 copay per day, days 1-100 Out-of-network: You pay 8% of the cost per day, days 1-100 Network: You pay a $25 copay per service Out-of-network: You pay a $55 copay per service Network: You pay 4% of the total cost of the service Out-of-network: You pay 8% of the total cost of the service Network: You pay 4% of the total cost of the service Out-of-network: You pay 8% of the total cost of the service
Aetna Medicare SM Plan (PPO) Annual Notice of Changes for 2016 13 SECTION 2 Other Changes Process 2015 (this year) 2016 (next year) For 2016, emergency care and urgently needed care benefits are not subject to your plan deductible. The out-of-pocket amounts that you pay for these benefits will no longer be credited towards the plan deductible value listed on page 1 of the Medical Benefits (Schedule of Copayments/Coinsurance) included in this booklet. SECTION 3 Deciding Which Plan to Choose Section 3.1 If you want to stay in Aetna Medicare Plan (PPO) If you decide to stay in the same Aetna Medicare plan, STRS Ohio will give you instructions if there is any action you need to take to remain enrolled. Section 3.2 If you want to change plans We hope to keep you as a member next year, but if you want to change for 2016 follow these steps: Step 1: Learn about and compare your choices You can join a different Medicare health plan. STRS Ohio will let you know what options are available to you under your group retiree coverage. You can switch to an individual Medicare health plan. -- OR-- You can change to Original Medicare. If you change to Original Medicare, you will need to decide whether to join a Medicare drug plan and whether to buy a Medicare supplement (Medigap) policy. It is important that you carefully consider your decision before dropping your STRS Ohio coverage. This is important because you may lose benefits you currently receive under STRS Ohio if you switch plans. If you are not currently entitled to Medicare Part A, you are enrolled in our plan through a special eligibility waiver. If you leave your group retiree coverage and want to join another Medicare Advantage plan, you may have to get Medicare Part A and pay an additional monthly premium. Call STRS Ohio for information.
Aetna Medicare SM Plan (PPO) Annual Notice of Changes for 2016 14 To learn more about Original Medicare and the different types of Medicare plans, read Medicare & You 2016, call your State Health Insurance Assistance Program (see Section 5), or call Medicare (see Section 7.2). You can also find information about plans in your area by using the Medicare Plan Finder on the Medicare website. Go to http://www.medicare.gov and click Find health & drug plans. Here, you can find information about costs, coverage, and quality ratings for Medicare plans. As a reminder, Aetna Medicare offers other Medicare health plans and Medicare prescription drug plans. These other plans may differ in coverage, monthly premiums, and cost-sharing amounts. Step 2: Change your coverage To change to a different Medicare health plan, enroll in the new plan. You will automatically be disenrolled from our plan. o To change to Original Medicare with a prescription drug plan, enroll in the new drug plan. You will automatically be disenrolled from our plan. To change to Original Medicare without a prescription drug plan, you must either: o Send us a written request to disenroll. Contact Customer Service if you need more information on how to do this (phone numbers are in Section 7.1 of this booklet). o or Contact Medicare, at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and ask to be disenrolled. TTY users should call 1-877-486-2048. SECTION 4 Deadline for Changing Plans You may be able to change to a different plan during STRS Ohio s open enrollment period. Your plan may allow you to make changes at other times as well. STRS Ohio will let you know what other plan options may be available to you. If you want to drop from your group retiree coverage and change to an Individual plan or to Original Medicare for next year, you can do it from October 15 until December 7. The change will take effect on January 1, 2016. It is important that you carefully consider your decision before dropping your STRS Ohio coverage. This is important because you may lose benefits you currently receive under STRS Ohio if you switch plans. Call STRS Ohio for information. Are there other times of the year to make a change? As a member of a group Medicare plan, you are eligible for a special enrollment period if you leave STRS Ohio s plan. In certain other situations, changes are also allowed at other times of the year. For example, people with Medicaid, those who get Extra Help paying for their drugs,
Aetna Medicare SM Plan (PPO) Annual Notice of Changes for 2016 15 and those who move out of the service area are allowed to make a change at other times of the year. For more information, see Chapter 8, Section 2.3 of the Evidence of Coverage. If you don t like your plan choice for 2016, you can switch to Original Medicare between January 1 and February 14, 2016. For more information, see Chapter 8, Section 2.2 of the Evidence of Coverage. SECTION 5 Programs That Offer Free Counseling about Medicare The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state. SHIPs are independent (not connected with any insurance company or health plan). They are state programs that get money from the Federal government to give free local health insurance counseling to people with Medicare. SHIP counselors can help you with your Medicare questions or problems. They can help you understand your Medicare plan choices and answer questions about switching plans. You can call your SHIP at the phone number in Addendum A at the back of the Evidence of Coverage. SECTION 6 Programs That Help Pay for Prescription Drugs You may qualify for help paying for prescription drugs. Below we list different kinds of help: Extra Help from Medicare. People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay up to 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not have a coverage gap or late enrollment penalty. Many people are eligible and don t even know it. To see if you qualify, call: o 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week; o The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778 (applications); or o Your State Medicaid Office (applications). Help from your state s pharmaceutical assistance program. Many states have state pharmaceutical assistance programs (SPAPs) that help people pay for prescription drugs based on their financial need, age, or medical condition. Each state has different rules. To learn more about the program, check with your State Health Insurance Assistance Program (the name and phone numbers for this organization are in Addendum A at the back of the Evidence of Coverage).
Aetna Medicare SM Plan (PPO) Annual Notice of Changes for 2016 16 What if you have coverage from an AIDS Drug Assistance Program (ADAP)? The AIDS Drug Assistance Program (ADAP) helps ADAP-eligible individuals living with HIV/AIDS have access to life-saving HIV medications. Medicare Part D prescription drugs that are also covered by ADAP qualify for prescription cost-sharing assistance. Note: To be eligible for the ADAP operating in your state, individuals must meet certain criteria, including proof of state residence and HIV status, low income as defined by the State, and uninsured/under-insured status. If you are currently enrolled in an ADAP, it can continue to provide you with Medicare Part D prescription cost-sharing assistance for drugs on the ADAP formulary. In order to be sure you continue receiving this assistance, please notify your local ADAP enrollment worker of any changes in your Medicare Part D plan name or policy number. Contact information for your state ADAP is shown on Addendum A at the back of the Evidence of Coverage. For information on eligibility criteria, covered drugs, or how to enroll in the program, please call your state ADAP (the name and phone numbers for this organization are in Addendum A at the back of the Evidence of Coverage). SECTION 7 Questions? Section 7.1 Getting Help from Aetna Medicare Plan (PPO) Questions? We re here to help. Please call Customer Service at the toll free telephone number on the back of your Aetna member ID card or our general customer service center at 1-866-282-0631. (For TTY assistance, please call 711). We re available for phone calls 8 a.m. to 8 p.m. local time, Monday through Friday. Calls to these numbers are toll free. Read your 2016 Evidence of Coverage (it has details about next year's benefits and costs) This Annual Notice of Changes gives you a summary of changes in your benefits and costs for 2016. For details, look in the 2016 Evidence of Coverage for our plan. The Evidence of Coverage is the legal, detailed description of your plan benefits. It explains your rights and the rules you need to follow to get covered services and prescription drugs. A copy of the Evidence of Coverage is included in this envelope. Visit our Website You can also visit our website at http://www.aetnaretireeplans.com. As a reminder, our website has the most up-to-date information about our provider network (Provider Directory).
Aetna Medicare SM Plan (PPO) Annual Notice of Changes for 2016 17 Section 7.2 Getting Help from Medicare To get information directly from Medicare: Call 1-800-MEDICARE (1-800-633-4227) You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Visit the Medicare Website You can visit the Medicare website (http://www.medicare.gov). It has information about cost, coverage, and quality ratings to help you compare Medicare health plans. You can find information about plans available in your area by using the Medicare Plan Finder on the Medicare website. (To view the information about plans, go to http://www.medicare.gov and click on Find health & drug plans. ) Read Medicare & You 2016 You can read Medicare & You 2016 Handbook. Every year in the fall, this booklet is mailed to people with Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most frequently asked questions about Medicare. If you don t have a copy of this booklet, you can get it at the Medicare website (http://www.medicare.gov) or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
Aetna Medicare SM Plan (PPO) 1 2016 Medical Benefits Chart (Schedule of Copayments/Coinsurance) AETNA LIFE INSURANCE COMPANY Contract Holder Name: STATE TEACHERS RETIREMENT SYSTEM OF OHIO Contract Holder Group Agreement Effective Date: 01/01/2016 Contract Holder Number: 455717 This Medical Benefits Chart (Schedule of Copayments/Coinsurance) is part of the Evidence of Coverage for Aetna Medicare Plan (PPO). When the Evidence of Coverage refers to the attachment for information on health care benefits covered under our plan, it is referring to this Medical Benefits Chart. (See Chapter 4, Medical Benefits Chart (what is covered and what you pay).) Annual Deductible FOR SERVICES RECEIVED NETWORK FOR SERVICES RECEIVED OUT-OF-NETWORK This is the amount you have to pay out of pocket before the plan will pay its share for your covered Medicare Part A and B services. $150 The annual in-network deductible does not apply to the following services: Preventive services, Part B drugs, diabetic supplies, emergency room visits, emergency ambulance, urgent care, renal care, acupuncture, wigs, lab work and any services where a copayment is applied, excluding skilled nursing and home health services. $500 Combined In- and Out-of- Network Deductible (Plan Level/includes network Deductible) The annual combined (plan level) deductible does not apply to the following out-of-network services: Preventive services, emergency room visits, emergency ambulance, and urgent care. Annual Maximum Out-of-Pocket Limit The maximum out-of-pocket limit applies to all covered Medicare Part A and B benefits including deductible. Maximum out-of-pocket amount for network services: $1,500 Combined maximum out-ofpocket amount for in- and out-ofnetwork services: $2,500 STRS_EGWP_CCP_L7_2016_Part_B_Only_PPO ME PPO SCH COPAY (Y2016)
Aetna Medicare SM Plan (PPO) 2 2016 Medical Benefits Chart (Schedule of Copayments/Coinsurance) Important information regarding the services listed below in the Medical Benefits Chart: If you receive services from: A primary care physician (PCP): Family Practitioner Pediatrician Internal Medicine General Practitioner And get more than one covered service during the single visit: An outpatient facility, specialist or doctor who is not a PCP and get more than one covered service during the single visit: Your plan services include: Copays only Copays and coinsurance Coinsurance only Copays only Copays and coinsurance Coinsurance only You will pay: One PCP copay. The PCP copay and the coinsurance amounts for each service. The coinsurance amounts for all services received. The highest single copay for all services received. The highest single copay for all services and the coinsurance amounts for each service. The coinsurance amounts for all services received. You will see this apple next to the Medicare covered preventive services in the benefits chart. Services that are covered for you What you must pay (after deductible listed on page 1) when you get these services network What you must pay (after deductible listed on page 1) when you get these services Out-of-network Abdominal aortic aneurysm screening A one-time screening ultrasound for people at risk. The plan only covers this screening if you have certain risk factors and if you get a referral for it from your physician, physician assistant, nurse practitioner, or clinical nurse specialist. There is no coinsurance, copayment, or deductible for beneficiaries eligible for this preventive screening. There is no coinsurance, copayment, or deductible for beneficiaries eligible for this preventive screening.
Aetna Medicare SM Plan (PPO) 3 2016 Medical Benefits Chart (Schedule of Copayments/Coinsurance) Services that are covered for you Acupuncture Acupuncture is provided as a supplemental benefit when plan criteria are met. It must be provided by practitioners who are licensed or certified, as applicable, in the state in which they practice and are furnishing services within the scope of practice defined by their licensing or certifying state. Ambulance services* Covered ambulance services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide care only if they are furnished to a member whose medical condition is such that other means of transportation could endanger the person s health or if authorized by the plan. The member s condition must require both the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary. Non-emergency transportation by ambulance is appropriate if it is documented that the member s condition is such that other means of transportation could endanger the person s health and that transportation by ambulance is medically required. If you require a Medicare covered round trip ambulance transport to a physician s office or dialysis center, you will pay a single cost-share for the round trip transport. *Prior authorization rules apply for air ambulance transfers and non-emergency transportation by ground ambulance or medical van. Prior authorization rules apply for network services and will be performed by your Aetna network provider. Aetna recommends pre-authorization of the service What you must pay (after deductible listed on page 1) when you get these services network $25 copay for each service 4% of the cost for each Medicare-covered ambulance benefit (one way) What you must pay (after deductible listed on page 1) when you get these services Out-of-network $55 copay for each service 8% of the cost for each Medicare-covered ambulance benefit (one way)
Aetna Medicare SM Plan (PPO) 4 2016 Medical Benefits Chart (Schedule of Copayments/Coinsurance) Services that are covered for you when provided by an out-of-network provider. What you must pay (after deductible listed on page 1) when you get these services network What you must pay (after deductible listed on page 1) when you get these services Out-of-network Annual physical exam The annual physical is an extensive physical exam including a medical history collection and it may also include any of the following: vital signs, observation of general appearance, a head and neck exam; a heart and lung exam; an abdominal exam; a neurological exam; a dermatological exam, and an extremities exam. Limited to one physical exam per year. $0 copay for the exam $0 copay for the exam Annual wellness visit If you ve had Part B for longer than 12 months, you can get an annual wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. This is covered once every 12 months. Note: Your first annual wellness visit can t take place within 12 months of your Welcome to Medicare preventive visit. However, you don t need to have had a Welcome to Medicare visit to be covered for annual wellness visits after you ve had Part B for 12 months. There is no coinsurance, copayment, or deductible for the annual wellness visit. There is no coinsurance, copayment, or deductible for the annual wellness visit. Bone mass measurement For qualified individuals (generally, this means people at risk of losing bone mass or at risk of osteoporosis), the following services are covered every 24 months or more frequently if medically necessary: procedures to identify bone mass, detect bone loss, or determine bone quality, including a physician s interpretation of the results. There is no coinsurance, copayment, or deductible for Medicarecovered bone mass measurement. There is no coinsurance, copayment, or deductible for Medicarecovered bone mass measurement.
Aetna Medicare SM Plan (PPO) 5 2016 Medical Benefits Chart (Schedule of Copayments/Coinsurance) Services that are covered for you What you must pay (after deductible listed on page 1) when you get these services network What you must pay (after deductible listed on page 1) when you get these services Out-of-network Breast cancer screening (mammograms) Covered services include: One baseline mammogram between the ages of 35 and 39 One screening mammogram every 12 months for women age 40 and older Clinical breast exams once every 24 months Cardiac rehabilitation services Comprehensive programs of cardiac rehabilitation services that include exercise, education, and counseling are covered for members who meet certain conditions with a doctor s referral. The plan also covers intensive cardiac rehabilitation programs that are typically more rigorous or more intense than cardiac rehabilitation programs. There is no coinsurance, copayment, or deductible for covered screening mammograms. $25 copay for each Medicare-covered cardiac rehabilitation visit There is no coinsurance, copayment, or deductible for covered screening mammograms. $55 copay for each Medicare-covered cardiac rehabilitation visit Cardiovascular disease risk reduction visit (therapy for cardiovascular disease) We cover 1 visit per year with your primary care doctor to help lower your risk for cardiovascular disease. During this visit, your doctor may discuss aspirin use (if appropriate), check your blood pressure, and give you tips to make sure you re eating well. There is no coinsurance, copayment, or deductible for the intensive behavioral therapy cardiovascular disease preventive benefit. There is no coinsurance, copayment, or deductible for the intensive behavioral therapy cardiovascular disease preventive benefit. Cardiovascular disease testing Blood tests for the detection of cardiovascular disease (or abnormalities associated with an elevated risk of cardiovascular disease) once every 5 years (60 months). There is no coinsurance, copayment, or deductible for cardiovascular disease testing that is covered once every 5 years. There is no coinsurance, copayment, or deductible for cardiovascular disease testing that is covered once every 5 years.
Aetna Medicare SM Plan (PPO) 6 2016 Medical Benefits Chart (Schedule of Copayments/Coinsurance) Services that are covered for you Cervical and vaginal cancer screening Covered services include: For all women: Pap tests and pelvic exams are covered once every 24 months If you are at high risk of cervical cancer or have had an abnormal Pap test and are of childbearing age: one Pap test every 12 months Chiropractic services We cover manual manipulation of the spine to correct subluxation What you must pay (after deductible listed on page 1) when you get these services network There is no coinsurance, copayment, or deductible for Medicarecovered preventive Pap and pelvic exams. 4% of the cost for each Medicare-covered visit What you must pay (after deductible listed on page 1) when you get these services Out-of-network There is no coinsurance, copayment, or deductible for Medicarecovered preventive Pap and pelvic exams. 8% of the cost of each Medicare-covered visit Colorectal cancer screening For people 50 and older, the following are covered: Flexible sigmoidoscopy (or screening barium enema as an alternative) every 48 months Fecal occult blood test, every 12 months For people at high risk of colorectal cancer, we cover: Screening colonoscopy (or screening barium enema as an alternative) every 24 months For people not at high risk of colorectal cancer, we cover: Screening colonoscopy every 10 years (120 months), but not within 48 months of a screening sigmoidoscopy There is no coinsurance, copayment, or deductible for a Medicare-covered colorectal cancer screening exam. There is no coinsurance, copayment, or deductible for a Medicare-covered colorectal cancer screening exam. Compression stockings You pay 4% per item You pay 8% per item
Aetna Medicare SM Plan (PPO) 7 2016 Medical Benefits Chart (Schedule of Copayments/Coinsurance) Services that are covered for you What you must pay (after deductible listed on page 1) when you get these services network What you must pay (after deductible listed on page 1) when you get these services Out-of-network Depression screening We cover 1 screening for depression per year. The screening must be done in a primary care setting that can provide follow-up treatment and referrals. There is no coinsurance, copayment, or deductible for an annual depression screening visit. There is no coinsurance, copayment, or deductible for an annual depression screening visit. Diabetes screening We cover this screening (includes fasting glucose tests) if you have any of the following risk factors: high blood pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Tests may also be covered if you meet other requirements, like being overweight and having a family history of diabetes. Based on the results of these tests, you may be eligible for up to two diabetes screenings every 12 months. Diabetes self-management training, diabetic services and supplies For all people who have diabetes (insulin and noninsulin users). Covered services include: Supplies to monitor your blood glucose: Blood glucose monitor, blood glucose test strips, lancet devices and lancets, and glucose-control solutions for checking the accuracy of test strips and monitors For people with diabetes who have severe diabetic foot disease: One pair per calendar year of therapeutic custom-molded shoes (including inserts provided with such shoes) and two additional pairs of inserts, or one pair of depth shoes and three pairs of inserts (not including the non-customized removable inserts provided There is no coinsurance, copayment, or deductible for the Medicare covered diabetes screening tests. $0 copay per Medicarecovered service or supply $0 copay for beneficiaries eligible for the Medicare-covered diabetes selfmanagement training preventive benefit. There is no coinsurance, copayment, or deductible for the Medicare covered diabetes screening tests. $0 copay per Medicarecovered service or supply $0 copay for beneficiaries eligible for the Medicarecovered diabetes selfmanagement training preventive benefit.
Aetna Medicare SM Plan (PPO) 8 2016 Medical Benefits Chart (Schedule of Copayments/Coinsurance) Services that are covered for you with such shoes). Coverage includes fitting. Diabetes self-management training is covered under certain conditions What you must pay (after deductible listed on page 1) when you get these services network What you must pay (after deductible listed on page 1) when you get these services Out-of-network Durable medical equipment and related supplies* (For a definition of durable medical equipment, see the final chapter ( Definitions of important words ) of the Evidence of Coverage.) Covered items include, but are not limited to: wheelchairs, crutches, hospital bed, IV infusion pump, oxygen equipment, nebulizer, and walker. We cover all medically necessary durable medical equipment covered by Original Medicare. If our supplier in your area does not carry a particular brand or manufacturer, you may ask them if they can special order it for you. 4% of the cost for each Medicare-covered item 8% of the cost for each Medicare-covered item Coverage for wigs is included when plan criteria is met. Wigs are covered at 4% of the cost up to $300 annually * Prior authorization rules apply for network services and will be performed by your Aetna network provider. Aetna recommends preauthorization of the service when provided by an out-of-network provider. Emergency care Emergency care refers to services that are: Furnished by a provider qualified to furnish emergency services, and Needed to evaluate or stabilize an emergency medical condition. A medical emergency is when you, or any other prudent layperson with an average knowledge of $65 copay for each Medicare-covered emergency room visit If you are immediately admitted to the hospital, you pay $0 for the emergency room visit $65 copay for each Medicare-covered emergency room visit If you are immediately admitted to the hospital, you pay $0 for the emergency room visit
Aetna Medicare SM Plan (PPO) 9 2016 Medical Benefits Chart (Schedule of Copayments/Coinsurance) Services that are covered for you health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse. This coverage is available worldwide. What you must pay (after deductible listed on page 1) when you get these services network What you must pay (after deductible listed on page 1) when you get these services Out-of-network If you receive emergency care at an out-of-network hospital and need inpatient care after your emergency condition is stabilized, you must move to a network hospital in order to pay the network cost-sharing amount for the part of your stay after you are stabilized. If you stay at the out-ofnetwork hospital, your stay will be covered but you will pay the out-ofnetwork cost-sharing amount for the part of your stay after you are stabilized. Deductible does not apply to emergency care. Health and wellness education programs Aetna Health Connections SM Disease Management This program provides individualized education and support for select chronic conditions. It can help you learn about how to manage your chronic health conditions and achieve your optimal state of health. Included in your plan Case Management Services A medical condition may qualify you for an individually assigned nurse case manager who will coordinate with your physicians to help so you can get well and stay healthy. Included in your plan
Aetna Medicare SM Plan (PPO) 10 2016 Medical Benefits Chart (Schedule of Copayments/Coinsurance) Services that are covered for you What you must pay (after deductible listed on page 1) when you get these services network What you must pay (after deductible listed on page 1) when you get these services Out-of-network Fitness Benefit The Aetna fitness benefit gives you free monthly membership at participating fitness clubs and facilities. Plan members who don t live close to a participating facility or want to exercise at home can order a home fitness kit. We work with another company to manage this benefit. Informed Health Line Talk to a registered nurse 24 hours a day, 7 days a week. Get answers about medical tests, procedures and treatment options. Telemonitoring for hypertension This program is designed to help members diagnosed with uncontrolled hypertension (defined as blood pressure >140/90) to manage their blood pressure. Members who choose to enroll in the program receive a free automatic blood pressure monitor, weekly calls to monitor their blood pressure and educational material. Some members may also receive extra support from a case manager. SilverSneakers Fitness Program is included in your plan. We re here to help and give you more information. Call us at 1-888-423-4632. (For TTY/TDD assistance please dial 711.) Visit http://www.silversneakers.com. Included in your plan Included in your plan Hearing services Medicare covered diagnostic hearing and balance evaluations performed by your provider to determine if you need medical treatment are covered as outpatient care when furnished by a physician, audiologist, or other qualified provider. Our plan covers one routine hearing exam every 12 months $25 copay for basic hearing evaluations $0 copay for one routine hearing exam every 12 months $55 copay for basic hearing evaluations $0 copay for one routine hearing exam every 12 months