Aetna Savings Plus Plan Guide

Transcription

1 Aetna Savings Plus Plan Guide For businesses with 2-50 eligible employees in the Chicagoland area Aetna Avenue Your Destination for Small Business Solutions Health Insurance plans are offered and/or underwritten by Aetna Life Insurance Company (Aetna). Plans effective October 1, IL (7/11)

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

4 Aetna makes it easier to manage your health plan Savings Plus plans include access to a robust suite of resources and online tools that save you time and money while helping your employees make better health decisions. Easy-to-navigate plans Aetna s health insurance plans are easy to set up, administer and use. Once enrolled, you will have access not only to your health insurance benefits, but also to online resources and information to help you and your employees make more informed decisions about your health. Aetna e-business for plan sponsors Aetna will help you save time and manage your benefits through a suite of innovative, easy-to-use online tools that support enrollment transactions. The benefits enrollment process is easier than ever, replacing paper-based enrollment with a secure, comprehensive electronic solution. Let Aetna be your guide With 150 years of experience, we can deliver the right solution for your small business. 2

5 Aetna Savings Plus service areas for Chicagoland Boone McHenry Lake DeKalb Kane DuPage Cook Kendall Will Lake Porter Grundy Kankakee Jasper Livingston Newton 3

6 Aetna small group Medical plan: Illinois Savings Plus Plan Options Plan Options IL oamc Savings Plus $500 80/50 IL oamc Savings Plus $ /50 Member Benefits PCP Referrals Required Plan Coinsurance (Applies to most services) In-Network Savings Plus designated network providers Out-of-Network 1 Non-designated/out-ofnetwork providers In-Network Savings Plus designated network providers Out-of-Network 1 Non-designated/out-ofnetwork providers No N/A No N/A Calendar Year Deductible 2 $500 per member $1,500 family $5,000 per member $15,000 family $1,000 per member $3,000 family $5,000 per member $15,000 family Calendar Year Out-of-Pocket Maximum 3 (Includes deductible; Excludes copayments and member cost-sharing for mental health, drug rehabilitation, DME and prescription drugs) $2,500 per member $7,500 family $15,000 per member $45,000 family $3,000 per member $9,000 family $15,000 per member $45,000 family Lifetime Maximum Benefit Unlimited Unlimited Primary Physician Office Visit Specialist Office Visit Outpatient Lab Outpatient X-ray Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET scans; Precertification required) Exams/Immunizations for Well Baby, Child and Adult; Routine GYN Exams and Routine Mammograms (Age/frequency schedules apply) Routine Eye Exam (One exam per 24 months; In and out-of-network Inpatient Hospital Outpatient Surgery Emergency Room (Copay waived if admitted) Urgent Care Durable Medical Equipment (Limited to $2,000 per member per calendar year; In and out-of-network Outpatient Physical/Occupational Therapy and Chiropractic Services (40 visits per calendar year; In and out-of-network Outpatient Speech Therapy (12 visits per calendar year; In and out-of-network Prescription Drugs (Includes insulin) (Retail: Per 30-day supply; Mail order: Two times retail copay, 31- to 90-day supply) $30 copay, deductible waived 50% $30 copay, deductible waived 50% $50 copay, deductible waived 50% $50 copay, deductible waived 50% $30 copay, deductible waived 50% $30 copay, deductible waived 50% $0 copay, deductible waived 50% $0 copay, deductible waived 50% $0 copay, deductible waived 50% $0 copay, deductible waived 50% $150 copay, deductible waived $150 copay, deductible waived $50 copay, deductible waived 50% $50 copay, deductible waived 50% $10/$40/$65 70% after $10/$40/$65 $10/$40/$65 70% after $10/$40/$65 90-Day Rx Transition of Coverage (TOC) for 4 Prior Certification Included Included 4 See page 7 for footnotes.

7 Aetna small group Medical plan: Illinois Savings Plus Plan Options Plan Options IL oamc Savings Plus CDHP $ /50 Member Benefits PCP Referrals Required In-Network Savings Plus designated network providers No Out-of-Network 1 Non-designated/out-ofnetwork providers N/A Plan Coinsurance (Applies to most services) Calendar Year Deductible 2 Calendar Year Out-of-Pocket Maximum 3 (Includes deductible; Excludes copayments and member cost-sharing for mental health, drug rehabilitation, DME and prescription drugs) $2,500 per member $7,500 family $4,500 per member $13,500 family $7,500 per member $22,500 family $22,500 per member $67,500 family Lifetime Maximum Benefit Primary Physician Office Visit Specialist Office Visit Outpatient Lab Outpatient X-ray Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET scans; Precertification required) Exams/Immunizations for Well Baby, Child and Adult; Routine GYN Exams and Routine Mammograms (Age/frequency schedules apply) Routine Eye Exam (One exam per 24 months; In and out-of-network Inpatient Hospital Outpatient Surgery Emergency Room (Copay waived if admitted) Urgent Care Durable Medical Equipment (Limited to $2,000 per member per calendar year; In and out-of-network Outpatient Physical/Occupational Therapy and Chiropractic Services (40 visits per calendar year; In and out-of-network Outpatient Speech Therapy (12 visits per calendar year; In and out-of-network Prescription Drugs (Includes insulin) (Retail: Per 30-day supply; Mail order: Two times retail copay, 31- to 90-day supply) 90-Day Rx Transition of Coverage (TOC) for Prior Certification 4 Unlimited $30 copay, deductible waived 50% $50 copay, deductible waived 50% $30 copay, deductible waived 50% $0 copay, deductible waived 50% $0 copay, deductible waived 50% $150 copay, deductible waived $50 copay, deductible waived 50% $10/$40/$65 70% after $10/$40/$65 Included See page 7 for footnotes. 5

8 Aetna small group Medical plan: Illinois Savings Plus Plan Options Member Benefits PCP Referrals Required Plan Coinsurance (Applies to most services) Plan Options In-Network Savings Plus designated network providers IL oamc Savings Plus HSA Comp $2500 (EMB) 90/50 Out-of-Network 1 Non-designated/out-ofnetwork providers IL oamc Savings Plus HSA Comp $3500 (EMB) 90/50 In-Network Savings Plus designated network providers Out-of-Network 1 Non-designated/out-ofnetwork providers No N/A No N/A Calendar Year Deductible 2 $2,500 per member $5,000 family $7,500 per member $15,000 family $3,500 per member $7,000 family $7,500 per member $15,000 family Calendar Year/Out-of-Pocket Maximum 3 (All amounts paid as deductible, copayment and coinsurance for covered medical and prescription drug expenses apply toward the out-of-pocket maximum) $5,000 per member $10,000 family $15,000 per member $30,000 family $5,500 per member $11,000 family $15,000 per member $30,000 family Lifetime Maximum Benefit Unlimited Unlimited Primary Physician Office Visit Specialist Office Visit Outpatient Lab Outpatient X-ray Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET scans; Precertification required) Exams/Immunizations for Well Baby, Child and Adult; Routine GYN Exams and Routine Mammograms (Age/frequency schedules apply) Routine Eye Exam (One exam per 24 months; In and out-of-network Inpatient Hospital Outpatient Surgery Emergency Room Urgent Care Durable Medical Equipment (Limited to $2,000 per member per calendar year; In and out-of-network Outpatient Physical/Occupational Therapy and Chiropractic Services (40 visits per calendar year; In and out-of-network Outpatient Speech Therapy (12 visits per calendar year; In and out-of-network $30 copay 50% $30 copay 50% $30 copay 50% $30 copay 50% $0 copay, deductible waived 50% $0 copay, deductible waived 50% $0 copay, deductible waived 50% $0 copay, deductible waived 50% 90% 90% $50 copay 50% $50 copay 50% Prescription Drugs (Includes insulin) (Retail: Per 30-day supply; Mail order: Two times retail copay, 31- to 90-day supply) $10/$40/$65 after integrated deductible 70% after $10/$40/$65 after integrated deductible $10/$40/$65 after integrated deductible 70% after $10/$40/$65 after integrated deductible 90-Day Rx Transition of Coverage (TOC) for 4 Prior Certification Included Included 6 See page 7 for footnotes.

9 FoOtnotes This is a partial description of benefits available; for more information, refer to the specific plan design summary. The dollar-amount copayments indicate what the member is required to pay, and the percentage amounts indicate what Aetna is required to pay. The deductible applies to all medical benefits unless otherwise stated. Some benefits are subject to limitations or visit maximums. Members or providers may be required to precertify or obtain prior approval for certain services. Note: For a summary list of Limitations and Exclusions, refer to the Aetna Avenue Illinois Plan Guide. Please refer to Aetna s Producer World website at for more detailed small business benefit descriptions. Or for more information, please contact your licensed agent or Aetna Sales Representative. 1. We cover the cost of care differently based on whether health care providers, such as doctors and hospitals, are in network or out of network. We want to help you understand how much Aetna pays for your out-of-network care. At the same time, we want to make it clear how much more you will need to pay for this out-of-network care. As an example, you may choose a doctor in our network. You may choose to visit an out-of-network doctor. If you choose a doctor who is out of network, your Aetna health plan may pay some of that doctor s bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital. When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the recognized or allowed amount. When you choose outof-network care, Aetna recognizes an amount based on what Medicare pays for these services. The government sets the Medicare rate. Your out-of-network doctor sets the rate to charge you. It may be higher sometimes much higher than what your Aetna plan recognizes or allows. Your doctor may bill you for the dollar amount that Aetna doesn t recognize. You must also pay any copayments, coinsurance and deductibles under your plan. No dollar amount above the recognized charge counts toward your deductible or maximum out-of-pocket. To learn more about how we pay out-of-network benefits visit Aetna.com. Type how Aetna pays in the search box. You can avoid these extra costs by getting your care from Aetna s broad network of health care providers. Go to and click on Find a Doctor on the left side of the page. If you are already a member, sign on to your Aetna Navigator member site. This way of paying out-of-network doctors and hospitals applies when you choose to get care out of network. When you have no choice (for example: emergency room visit after a car accident), we will pay the bill as if you got care in network. You pay your plan s copayments, coinsurance and deductibles for your in-network level of benefits. Contact Aetna if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your copayments, coinsurance and deductibles. 2. Once the family deductible is met, all family members will be considered as having met their deductible for the remainder of the calendar year. No one family member may contribute more than the individual deductible amount to the family deductible. In and out-of-network costs accumulate separately. 3. Once the family out-of-pocket maximum is met, all family members will be considered as having met their out-of-pocket maximum for the remainder of the calendar year. No one family member may contribute more than the individual out-of-pocket maximum amount to the family out-of-pocket maximum. In and out-of-network costs accumulate separately. 4. Transition of Coverage for Prior Certification helps members of new groups to transition to Aetna by providing a 90-calendar-day opportunity, beginning on the group s initial effective date, during which prior authorization requirements will not apply to certain drugs. Once the 90 calendar days have expired, prior authorization edits will apply to all drugs requiring prior authorization as listed in the formulary guide. Members who have claims paid for a drug requiring prior authorization during the Transition of Coverage period may continue to receive this drug after the 90 calendar days and will not be required to obtain a prior authorization. 7

10 Underwriting guidelines Aetna Savings Plus Plans n Underwriting guidelines for the Savings Plus plans follow the same guidelines as the Illinois Small Group Standard portfolio. n Plans can be offered as a triple option next to a Standard plan in the portfolio. n Plans cannot be offered to employees out of state (OOS) or outside one of the specified counties/zip codes. n Eligible employees must reside or work in the Savings Plus area. MULTI-OPTION OFFERINGS Greater employee choice Employers can offer any of the available Standard plan designs, including Savings Plus plans. Flexibility and affordability Employers can create a customized benefits package from any of our plan types and plan designs. Aetna offers a variety of plans at different price points. Employers may designate a level of contribution that meets their budget. Total freedom Aetna offers plan choices that range in price and benefits to help meet each individual employee s needs, whether they are lower premiums or lower out-of-pocket costs at the time services are received. Easy administration Setting up this program is simple: 1. The employer chooses up to 3 of the available plans to offer on the Employer Application. 2. The employer chooses how much to contribute. 3. Each employee chooses the plan that s right for him or her. Multi-Option Offerings Target Audience Plan Choices Minimum Participation 1 4 Enrolled Employees 5 50 Enrolled Employees Employer Contribution Every small business with 5+ enrolled employees Up to 3 of the available plans Choice of 1 plan Choice of up to 3 plans, minimum of 1 employee in each plan n 50% of employee-only premium or a minimum defined contribution of $120 per employee per month n The employer cannot fund the deductible in excess of 50% annually, whether through an HRA, HSA or any other funding arrangement n Coverage can be denied based on inadequate or excess contributions Rating options 1 4 Enrolled Employees Tabular 5 50 Enrolled Employees Option of tabular or composite 8

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14 Contact us For more information regarding the Aetna Savings Plus plans for Chicagoland, please contact your Aetna representative. Aetna Avenue Your Destination for Small Business Solutions This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits may vary by location. Health insurance plans contain exclusions and limitations. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Plan features and availability may vary by location and group size. Plan For Your Health is a public education program from Aetna and The Financial Planning Association. Providers are independent contractors and not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features are subject to change. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna s Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a licensed pharmacy subsidiary of Aetna Inc. that operates through mail order. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to Aetna Inc IL (7/11)