Aetna Whole Health SM PrimeCare Physicians Plans

Transcription

1 Aetna Whole Health SM PrimeCare Physicians Plans For businesses with eligible employees in California, located in the Inland Empire Riverside and San Bernardino counties CA (11/12)

2 Health benefits and health insurance plans are offered and/or underwritten by Aetna Health of California Inc. and/or Aetna Life Insurance Company (Aetna). 2

3 Aetna Whole Health brings you PrimeCare Physicians Plans Aetna and PrimeCare have formed a distinct collaboration to offer businesses a unique opportunity to help their employees optimize and manage their health. The cornerstone to this health benefits and insurance plan is the collaboration between Aetna and PrimeCare physicians working together to make health care work better to lower costs and help improve patient health care through: Personalized care and engagement that better meets the needs of members Shared accountability and shared cost savings among providers through greater care coordination The providers of PrimeCare Physicians Plans are teaming with Aetna to provide a more complete patient experience. By working together to use information technology to coordinate care, deliver clinical decision support and get people more engaged in their overall health and well-being, this leads to better care efficiencies and may provide more effective health outcomes for the residents of the Inland Empire. Why is coordinated care important to members? Coordinated care enables doctors to provide care more effectively and communicate better with members and other doctors in the network. It means that doctors in the network are working together to build a care plan around the member. And that doctors in the network will be able to share information about the member s care more easily with each other to provide a more complete patient experience. The bottom line? Coordinated care is simply more effective and efficient. This can help give a better care experience and cut down on duplicate medical tests and other things that increase medical costs. And that s better for everyone. We re pleased to offer the PrimeCare network for businesses located in the Inland Empire PrimeCare is a network* of providers helping to improve care while decreasing costs for members and employers. Members will find care in their own communities with local health care providers who have broad skill, experience and compassion. This health benefits/health insurance plan provides convenient access to an integrated network of providers dedicated to maintaining and enhancing health at the highest possible level, while delivering a highly coordinated patient experience using real-time information and decision support tools at the time of patient interaction. The PrimeCare network offers Affordability that meets the needs of employers looking to lower their costs while providing quality health care. Independent physicians who pride themselves on being a part of their communities and getting to know each patient. Many of the doctors have treated two, three or more generations of the same family. Many conveniently located primary care doctors, specialists, hospitals, lab and X-ray centers. Local urgent care centers within the community provide nonemergency, urgent care after physicians office hours practical for accommodating busy schedules. *PrimeCare physicians are independently contracted. Easily locate Aetna Whole Health Designated Providers online. Go to Aetna DocFind: 3

4 PrimeCare network Choosing a physician PrimeCare Physicians Plans are available to Inland Empire small businesses with employees residing in the Riverside/ San Bernardino counties: For individually contracted HMO benefits plans, members must select a primary care physician (PCP) from the PrimeCare network. For Managed Choice insurance plans, members may seek care within the PrimeCare network to maximize their savings. PrimeCare Provider Groups PrimeCare Chino Valley PrimeCare of Redlands PrimeCare of Citrus Valley PrimeCare of Riverside PrimeCare of Corona PrimeCare of San Bernardino PrimeCare of Hemet Valley PrimeCare of Sun City PrimeCare of Inland Valley PrimeCare of Temecula PrimeCare of Moreno Valley Valley Physicians Network PrimeCare Physicians are independently contracted. To make sure your PrimeCare physicians are participating in the Aetna Whole Health Designated provider network, visit our DocFind directory at 4

5 Los Angeles San Bernardino Chino Valley Inland Valley San Bernardino Redlands Citrus Valley Riverside Moreno Valley Corona Riverside Valley Sun City Hemet Valley PrimeCare locations Hospitals Temecula Hospital City Address Corona Regional Medical Center Corona 800 South Main Street Hemet Valley Medical Center Hemet 1117 East Devonshire Ave. Inland Valley Regional Medical Center Wildomar Inland Valley Drive Loma Linda University Medical Center Murrieta Murrieta Baxter Road Loma Linda University Medical Center Tertiary Care Loma Linda Anderson Street Menifee Valley Medical Center Sun City McCall Blvd. Parkview Community Hospital Medical Center Riverside 3865 Jackson Street Pomona Valley Hospital Medical Center Pomona 1798 North Garey Ave. Rancho Springs Medical Center Murrieta Medical Center Drive Redlands Community Hospital Redlands 350 Terracina Blvd. Riverside Community Hospital Riverside 4445 Magnolia Ave. San Antonio Community Hospital Upland 999 San Bernardino Road San Gorgonio Memorial Hospital Banning 600 North Highland Springs Ave. Community Hospital of San Bernardino San Bernardino 1805 Medical Center Drive St. Bernardine Medical Center San Bernardino 2101 North Waterman Ave. 5

6 New health plans designed with businesses in mind For Riverside and San Bernardino counties PrimeCare Physicians Plans are helping California businesses access health services that fit their needs and their budgets. They give members access to an affordable network of health providers right in their own community. Same quality local care at a lower cost PrimeCare Physicians Plans provide Inland Empire members with the same types of coverage as other Aetna medical plans, but at a lower premium cost. Savings are generated through the use of the PrimeCare network, a quality network of local health care providers. The plans also: Premiums and out-of-pocket expense levels vary select the plan that s right for you and your employees. Cover doctor s office visits, hospital stays and preventive care Include prescription drugs Provide access to a secure member self-service website How do PrimeCare Physicians Plans work? Aetna Whole Health-PrimeCare Physicians Plans offer a wide variety of Managed Choice and HMO plans in California, giving businesses the flexibility and the choice to best meet their needs. HMO plans Members must use the PrimeCare network to coordinate all of their care. HMO plans feature lower out-of-pocket costs than Managed Choice plans. Members pay copays for physicians, lab and X-rays. Managed Choice plans Each Managed Choice plan has two levels of benefits: Level 1: When members use the PrimeCare network to coordinate all of their care, they realize maximum savings. Level 2: Use of any other providers will result in a lower level of benefits. While Aetna Whole Health members have the freedom to receive care from any hospital or provider, they realize the highest benefit level and the lowest out-of-pocket costs when they access care through the PrimeCare network. All PrimeCare Physicians Plans include coverage for doctor s office visits, hospital stays, preventive care, pharmacy and more. 6

7 Limitations and exclusions These plans do not cover all health care expenses and include exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, the plan documents may contain exceptions to this list based on state mandates or the plan design purchased. Aetna HMO All medical and hospital services not specifically covered, or which are limited or excluded by the plan documents, including costs of services before coverage begins and after coverage terminates Certain over-the-counter medications and supplies Cosmetic surgery Custodial care Dental care and dental X-rays Donor egg retrieval Experimental and investigational procedures (except for coverage for medically necessary routine patient care costs for members participating in a cancer clinical trial) Hearing aids Home births Immunizations for travel or work* Implantable drugs and certain injectable drugs, including injectable infertility drugs Infertility services, including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in the plan documents Nonmedically necessary services or supplies Radial keratotomy or related procedures Reversal of sterilization Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies or counseling Special-duty nursing Aetna Managed Choice All medical or hospital services not specifically covered, or which are limited or excluded in the plan documents Certain over-the-counter medications and supplies Charges related to any eye surgery mainly to correct refractive errors Cosmetic surgery, including breast reduction Custodial care Dental care and X-rays Donor egg retrieval Experimental and investigational procedures (except for coverage for medically necessary routine patient care costs for members participating in a cancer clinical trial) *California members are covered for all indicated or medically necessary immunizations. Hearing aids Infertility services, including, but not limited to, artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in the plan documents Nonmedically necessary services or supplies Orthotics, as specified in the plan Reversal of sterilization Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies or counseling Special-duty nursing Those for or related to treatment of diet or weight control Pre-existing conditions exclusion provision These plans impose a pre-existing conditions exclusion, which may be waived in some circumstances (that is, creditable coverage) and may not be applicable to everyone. A pre-existing conditions exclusion means that if an individual has a medical condition before coming to our plan, he or she might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis or treatment was recommended or received, or for which the individual took prescribed drugs within six months. The exclusion period, if applicable, may last up to six months from the first day of coverage, or if there is a waiting period, from the first day of the waiting period. If an individual had less than six months of group or three months of individual (including Medicare, Medicaid and Medi-Cal) creditable coverage immediately before the date he or she enrolled, the plan s pre-existing conditions exclusion period will be reduced by the amount (that is, number of days) of that prior coverage. If the individual had no prior creditable coverage within the six months for group or three months for individual prior to his or her enrollment date (either because he or she had no prior coverage or because there was more than a six months of group or three months of individual gap from the date the individual s prior coverage terminated to the enrollment date), we will apply the plan s pre-existing conditions exclusion. In order to reduce or possibly eliminate the plan s exclusion period based on creditable coverage, individuals should provide us a copy of any Certificates of Creditable Coverage they have. Please contact Aetna Member Services at for PPO and for HMO for assistance in obtaining a Certificate of Creditable Coverage from prior carrier or if there are any questions on the information noted above. Pre-existing condition exclusion provisions are waived for any individual under the age of 19 and do not apply to pregnancy. Note: For late enrollees, coverage will be delayed until the plan s next open enrollment; if applicable, the pre-existing exclusion will be applied from the individual s effective date of coverage. 7

8 Contact us For more information regarding PrimeCare Physicians Plans for California, please contact your Aetna Account Executive or our Small Group Broker Services Team toll free at , option 6. This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits may vary by location. Health benefits and health insurance plan contain exclusions and limitations. Plan features and availability may vary by location and group size. Providers are independent contractors and not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features are subject to change. If you are in a plan that requires the selection of a primary care physician and your primary care physician is part of an integrated delivery system or physician group, your primary care physician will generally refer you to specialists and hospitals that are affiliated with the delivery system or physician group. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to Aetna Inc CA (11/12)