Waynesboro City Schools New benefit year on an Aetna benefit plan - 2016 Quality health plans &...
-
Upload
bryce-williamson -
Category
Documents
-
view
220 -
download
0
Transcript of Waynesboro City Schools New benefit year on an Aetna benefit plan - 2016 Quality health plans &...
Waynesboro City SchoolsNew benefit year on an Aetna benefit plan - 2016
Quality health plans & benefitsHealthier livingFinancial well-beingIntelligent solutions
2
New benefit year on an Aetna benefit plan
What’s happening?
Benefit design basics and network
Medical Plan Options
The Aetna Advantage: Member tools and information
─ Helping members get started with Aetna
Questions?
2
3
Medical benefit design basics with valuable featuresAetna Choice Point of Service II (Open Access)• Open access models
─ Selecting a PCP is not required─ Referrals are not required─ Access to national network of providers when traveling
• National Advantage Program (NAP) supports contracted rates for out-of-network claims
• Complete details in Plan Design documents• Benefits will be processed based on type of service and place of service
─ Ex: Office visit that includes surgical procedure is covered with an office visit copay.
─ Ex: Dialysis/chemo follow place of service and type of service. If done in the office then follow office cost share, if done outpatient hospital, it follows the outpatient hospital benefit
Your benefit design and network
44
Medical benefit design basics with valuable features (continued)
• Lab – Quest is preferred vendor; Lab Corp is non-par. Lab services can be done at participating hospitals as well.
• Maternity ultrasounds are no longer covered at 100%, will follow place of service and type of service
• Urgent Care has an in and out of network cost share. Urgent Care Center (UCC) must be used for urgent care only, routine care not covered at UCC.
• Non-par provider (Emergency, Ambulance and HAIRPENS*) Aetna pays these providers the ‘reasonable rate.’ Member is held harmless for any balance billing upon member appeal (call to member services).
• Addition of Teladoc benefit and 24/7 nurseline• Coverage for routine eye exam (refraction) will continue to be covered as
part of your medical planHAIRPENS (Hospitalists, Anesthesiologist, Intensivists, Radiologists, Pathologists, Emergency Physicians and Neonatologists)
5
Important information about your pharmacy plan
Your benefit design and network
Your formulary will be referred to as Aetna ValueWhat remains the same?• Copay structures and benefit details • Current member restrictions (use of a single provider or pharmacy) remain in place for
controlled substances
What is changing?
• Mail order benefit is 2 copays for 90 day supply for all tiers
• Days supply will be 30 day supply
What will be immediately available to members?• Open prior authorizations • Active prescriptions for mail order delivery
When will new prescriptions be needed? • Some specialty drugs, and controlled substances, expired prescriptions,
prescriptions with no refills will not transfer to mail order pharmacy upon renewal and will require new prescriptions
Details in Plan Design document
6
Provider network –
Your benefit design and network
• Nearly all physicians in the current Coventry network are also in Aetna’s network.
Primary Care Physicians Specialists Hospitals
Virginia - 4,823 National – 224,329
Virginia - 8,312 National - 418,031
Virginia - 95 National - 5,602
Medical Plan Options
Open Choice POS II High Plan
8
In-Network Care Out-of-Network Care
DeductibleIndividualFamily
$500$1,000
$500$1,000
Out of Pocket MaximumIndividualFamily
$3,000$6,000
$3,000$16,000
Coinsurance 20% 30%*after deductible
Preventive Care Covered at 100% 30%*; after deductible
PCPSpecialistEmergency RoomUrgent CareInpatientOutpatient
$25 copay$50 copay
20%; after deductible$75 copay
20%; after deductible20%; after deductible
30%*; after deductible30%*; after deductible
Same as in-network care30%*; after deductible30%*; after deductible30%*; after deductible
Retail RX
Mail Order Drug
$10/$30/$60
$20/$60/$120
Not covered
Not covered
* Percentage shown is of the Reasonable and Customary amount. Member is also responsible for the difference between the billed amount and the Reasonable and Customary amount.
Open Choice POS II Low Plan
9
In-Network Care Out-of-Network Care
DeductibleIndividualFamily
$1,000$2,000
$1,000$2,000
Out of Pocket MaximumIndividualFamily
$4,000$8,000
$4,000$8,000
Coinsurance 30% 40%*after deductible
Preventive Care Covered at 100% 40%*; after deductible
PCPSpecialistEmergency RoomUrgent CareInpatientOutpatient
$25 copay$50 copay
30%; after deductible$75 copay
30%; after deductible30%;after deductible
40%*; after deductible40%*; after deductible
Same as in-network care40%*; after deductible40%*; after deductible40%*; after deductible
Retail RX
Mail Order Drug
$10/$30/$60
$20/$60/$120
Not covered
Not covered
* Percentage shown is of the Reasonable and Customary amount. Member is also responsible for the difference between the billed amount and the Reasonable and Customary amount.
The Aetna Advantage
11
Aetna Navigator® helps members manage their health and benefits
• Review claims • Find a doctor • Look up health
information • Get an ID card • Research costs of care
Secure, easy-to-use website lets members:
Personalized health information is available 24/7
Member tools and information
The secure Coventry member website, My Online ServicesSM, will be active for 24 months from the start date of your Aetna plan. TIP
12
Ask Ann online assistant
Member telephone service
Aetna Mobile
New tools and features for members support when and where they need it
Member tools and information
13
Members connect with us – wherever, whenever through Aetna Mobile
• Find a doctor or urgent care center• Research claims• Get an ID card• Price-a-DrugSM
• Access their personal health record
Optimized for most devices
14
Members find a doctor easily with DocFind® search tool
Your employees use our online DocFind search tool to find a doctor, pharmacy or dentist close to you, in our networks.• Easy to search• Comprehensive results
screens• Clean pages
Member tools and information
15
• Find out what can be wrong and where to go for treatment
• Search symptoms, conditions and treatment options
• Book appointments (certain locations)
• Use special tools just for Aetna members– Information tailored to your plan– Access ID cards– See claims history
iTriage® – Engages members with powerful information
Member tools and information
16
Changes for members:
Member tools and information
New ID cards with new features Family ID card that shows up to five family members• New ID cards will go out as renewals/new
enrollments occur• ID cards will also be available to view and
print on Aetna Navigator®• Member Services phone number and claims
mailing address are on the new ID card• Health plan product name and group
number (control number) are on the front of the ID card
It is important for members to give
providers their new ID card to use their new member ID number.
17
1) A Family* Explanation of Benefits (EOB) will have a new look making it easier for members to understand claim activity
2) Track spending, savings and deductibles.
3) View common EOB terms with definitions. After the definitions, it shows totals for charges.
4) Get helpful messages from Aetna or your employer.
5) Get a payment summary for claims on the EOB.
6) See detailed information for each claim on your EOB.
Changes for members: Aetna family EOB
Member tools and information
1
2
3
4
5
*Unless an individual EOB is required by a state.
18
Helping to support a smooth member experienceUpon renewal, a member’s current information will be transferred, including: Open Prior Authorizations:
─ Referrals to specialists, pre-certifications and pharmacy programs. Mail order prescriptions with refills remaining.
Member Demographics: ─ Coordination of Benefits ─ PCP selections─ Preferences such as privacy and paper suppression
Transition of Care – Reviewed case by case upon request
Provider lookup - http://www.aetna.com/dse/search?site_id=dse
Formulary lookup - http://client.formularynavigator.com/Search.aspx?siteCode=5902821386
Helping members get started
1919
Questions?