A Quick Look at Your Health Plan Wichita Public Schools

Transcription

1 A Quick Look at Your Health Plan Wichita Public Schools When you enroll with, you re taking the next step towards a healthier, more balanced you. It s important for you to understand how your health plan works. This way, you can make the changes you want in your health and in your life. Get the support you need for a healthy balance Chances are, you try every day to keep a healthy balance in your life. But me can get away from you, or you might put other details first. That s why we re here: to help you focus and to support you each step of the way. You can think of your healthcare benefits as your resource to protect your body, mind and spirit , Inc. All rights reserved.

2 Benefit Highlights Nationwide provider access at a discount When you and your family seek healthcare services, you have access to Aetna s broad na onal provider network of healthcare providers and facili es. Aetna s network contains more than 664,000 par cipa ng physicians and ancillary providers, with 5,667 hospitals. 1 When you visit providers in the Aetna network, you will receive services at strong, nego ated rates, helping you to save on the cost of healthcare. 1 h ps:// aetna-facts.html Locate your preferred providers With Aetna s comprehensive provider par cipa on, many of your preferred doctors may already be in the Aetna network. Please note: You have two provider networks. To verify whether or not a doctor or healthcare facility par cipates, visit h p:// Member Statements Member Statements are a document that replaces your Explana on of Benefits document, or EOB. The layout is similar to a bank statement, with a design that is straight-forward and easier to review than an EOB. You ll receive a member statement for each month in which you had claim ac vity. The statement will list all claims processed in the preceding month. In addi on, member statements contain health ps and sugges ons. Along with healthcare claims, member statements track your deduc ble. This informa on is helpful for you to manage your benefits, including your healthcare dollars. If you remain in favor of EOBs, don t worry. They re s ll available online and will con nue to be sent only in cases of coverage denials, when they will contain instruc ons for filing appeals. 24x7 Nurse Line Call anytime, day or night What do you do when you re not sure what to do?: When you don t know where to go for care (is it really an emergency?). When it s 4:00 a.m. and your child can t stop coughing? When you ve taken a tumble and your ankle is swelling? Now you can call the 24x7 Nurse Line to talk to a registered nurse who will listen and give you professional, seasoned advice, making sure you get care in the right place at the right me. When you call, you can also tap into our health informa on library, a collec on of more than 1,100 health topics, many available in Spanish or English. One more great support feature for plan par cipants: Our nurse counselors can connect you to community resources, like support groups, classes and seminars. 2

3 Benefit Highlights On-demand medical advice from qualified physicians Your Teladoc program With Teladoc, you can contact board-cer fied, licensed doctors by phone or , 24 hours a day! Some mes you need to speak with a doctor when it s not possible to a end an office visit. That s why the Teladoc program is available to you and your family, and can be used in a variety of ways: During weekends, holidays or a er business hours, when general prac oners don t typically schedule appointments. When you can t a end a medical appointment, such as when traveling or at work. If you need a prescrip on medica on or refill for a common condi on. Contact a Teladoc physician at , or send an by logging in at for advice on commonly treated condi ons. Some of these services include: Headaches/migraines Stomach ache/diarrhea Respiratory infec ons Urinary tract infec ons Prescrip on refills* Many other condi ons 2015 Teladoc, Inc. All rights reserved. Teladoc and the Teladoc logo are registered trademarks of Teladoc, Inc. and may not be used without wri en permission. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescrip on will be wri en. Teladoc operates subject to state regula on and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, non therapeu c drugs and certain other drugs which may be harmful because of their poten al for abuse. Teladoc physicians reserve the right to deny care for poten al misuse of services. Teladoc phone consulta ons are available 24 hours, 7 days a week while video consulta ons are available during the hours of 7am to 9pm, 7 days a week. 3

4 Benefits Summary Base Plan Premium Option 1 Plan IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK MAJOR MEDICAL Deductible (Ded) $4,500/Individual $9,000/Individual $1,500/Individual $3,000/Individual $9,000/Family $18,000/Family $3,000/Family $6,000/Family Out-of-Pocket Maximum $6,150/Individual $12,300/Individual $4,500/Individual $9,000/Individual (Including Deductible, Copayments & Coinsurance) $12,300/Family $24,600/Family $9,000/Family $18,000/Family Co-Insurance 70% Plan Pays 50% Plan Pays 70% Plan Pays 50% Plan Pays PREVENTIVE CARE 100%, Deductible Waived Not Covered 100%, Deductible Waived Not Covered TELADOC $15 Copay Not Covered $15 Copay Not Covered PHYSICIANS OFFICE VISITS $30 Copay Deduct then 50% $30 Copay Deduct then 50% SPECIALIST OFFICE VISITS $50 Copay Deduct then 50% $50 Copay Deduct then 50% CONVENIENCE CLINIC $30 Copay Not Covered $30 Copay Not Covered URGENT CARE $50 Copay $50 Copay EMERGENCY ROOM $100 Copay plus In-Network Deduct then 30% $100 Copay plus In-Network Deduct then 30% AMBULANCE TESTING In-Network Deduct then 30% In-Network Deduct then 30% Diagnostic Test (x-ray, blood work) $30 Copay Deduct then 50% $30 Copay Deduct then 50% Imaging (CT/PET scans, MRI) $100 Copay plus Deduct then 30% Deduct then 50% $100 Copay plus Deduct then 30% Deduct then 50% OUTPATIENT SURGERY Deduct then 30% Deduct then 50% Deduct then 30% Deduct then 50% HOSPITAL INPATIENT CARE Deduct then 30% Deduct then 50% Deduct then 30% Deduct then 50% MENTAL and BEHAVIORAL HEALTH, SUBSTANCE ABUSE Outpatient Services $50 Copay Deduct then 50% $50 Copay Deduct then 50% Inpatient Services Deduct then 30% Deduct then 50% Deduct then 30% Deduct then 50% MATERNITY CARE Office Visits No Charge Deduct then 50% No Charge Deduct then 50% Childbirth/delivery professional $50 Copay Deduct then 50% $50 Copay Deduct then 50% Childbirth/delivery facility Deduct then 30% Deduct then 50% Deduct then 30% Deduct then 50% HOME HEALTH CARE Deduct then 30% Deduct then 50% Deduct then 30% Deduct then 50% SKILLED NURSING CARE Deduct then 30% Deduct then 50% Deduct then 30% Deduct then 50% HOSPICE Deduct then 30% Deduct then 50% Deduct then 30% Deduct then 50% REHABILITATION SERVICES Deduct then 30% Deduct then 50% Deduct then 30% Deduct then 50% DURABLE MEDICAL EQUIPMENT Deduct then 30% Deduct then 50% Deduct then 30% Deduct then 50% PRESCRIPTION DRUG CARD Out-of-Pocket Maximum $1,000/Individual Not Covered $2,650/Individual Not Covered (Separate from Medical) $2,000/Family Not Covered $5,300/Family Not Covered Retail (31 days supply) Generic $10 Copay Not Covered $10 Copay Not Covered Preferred $30 Copay Not Covered $30 Copay Not Covered Non-Preferred $55 Copay Not Covered $55 Copay Not Covered Specialty 10% up to max of $100 Not Covered 10% up to max of $100 Not Covered Mail Order (32-93 days supply) Generic $20 Copay Not Covered $20 Copay Not Covered Preferred $60 Copay Not Covered $60 Copay Not Covered Non-Preferred $110 Copay Not Covered $110 Copay Not Covered 4

5 Benefits Summary IN-NETWORK Premium Option 2 Plan OUT-OF-NETWORK MAJOR MEDICAL Deductible (Ded) $2,000/Individual $4,000/Individual $4,000/Family $8,000/Family Out-of-Pocket Maximum $6,000/Individual $12,000/Individual (Including Deductible, Copayments & Coinsurance) $12,000/Family $24000/Family Co-Insurance 70% Plan Pays 50% Plan Pays PREVENTIVE CARE 100%, Deductible Waived Not Covered TELADOC $15 Copay Not Covered PHYSICIANS OFFICE VISITS $30 Copay Deduct then 50% SPECIALIST OFFICE VISITS $50 Copay Deduct then 50% CONVENIENCE CLINIC $30 Copay Not Covered URGENT CARE $50 Copay EMERGENCY ROOM AMBULANCE $100 Copay plus In-Network Deduct then 30% In-Network Deduct then 30% TESTING Diagnostic Test (x-ray, blood work) $30 Copay Deduct then 50% Imaging (CT/PET scans, MRI) $100 Copay plus Deduct then 30% Deduct then 50% OUTPATIENT SURGERY Deduct then 30% Deduct then 50% HOSPITAL INPATIENT CARE Deduct then 30% Deduct then 50% MENTAL and BEHAVIORAL HEALTH, SUBSTANCE ABUSE Outpatient Services $50 Copay Deduct then 50% Inpatient Services Deduct then 30% Deduct then 50% MATERNITY CARE Office Visits No Charge Deduct then 50% Childbirth/delivery professional $50 Copay Deduct then 50% Childbirth/delivery facility Deduct then 30% Deduct then 50% HOME HEALTH CARE Deduct then 30% Deduct then 50% SKILLED NURSING CARE Deduct then 30% Deduct then 50% HOSPICE Deduct then 30% Deduct then 50% REHABILITATION SERVICES Deduct then 30% Deduct then 50% DURABLE MEDICAL EQUIPMENT Deduct then 30% Deduct then 50% PRESCRIPTION DRUG CARD Out-of-Pocket Maximum $1,150/Individual Not Covered (Separate from Medical) $2,300/Family Not Covered Retail (31 days supply) Generic $10 Copay Not Covered Preferred $30 Copay Not Covered Non-Preferred $55 Copay Not Covered Specialty 10% up to max of $100 Not Covered Mail Order (32-93 days supply) Generic $20 Copay Not Covered Preferred $60 Copay Not Covered Non-Preferred $110 Copay Not Covered 5

6 Your Guide to Enrollment The final step toward better balance and better living A er you ve completed enrollment, your employer has approved it and a er any wai ng period has passed, your benefits will be effec ve. Your ID Card will be on its way to you soon. The card shows as your health plan administrator. Keep it in your wallet and carry it with you. Sample ID Card ABC Company Group #: Member: JOHN Q SAMPLE Member ID: Division: 001 Dependent: JANE W SAMPLE JOHN Q SAMPLE JR Customer Service and Eligibility Inquiries Coverage: Plan: Aetna Choice POS II Office Visit $XX Specialist $XX Urgent Care $XX Emergency Room $XX RXBIN: RXPCN: ADV RXGRP: RX2738 Member: Pharmacy: Generic $XX Formulary $XX Non-Formulary $XX Helpful Tips Your healthcare plan includes a network of providers you can visit for healthcare services. When you visit providers in this network, you will receive the best service rate. Call the provider information number for participating providers. Your name, identification number, medical group number and your group name, are used to identify you and your covered dependents benefits. Your medical copays are listed for you and your providers. Your pharmacy coverage information is listed on the front of your card, and includes customer service number and prescrip on copays. Please ensure that you precertify with medical management, if required. All claims should be submitted to at the address listed on the back of your card. You or your provider can call to verify eligibility of benefits or check on your claims status. You can call for information on a doctor or specialist who is close to you and serves your specific needs. Provider Claims: PO Box Richardson TX EDI: WebMD/Emdeon or McKesson/ Relay Health 1761 Correspondence & Member Submissions: PO Box Minneapolis MN EDI: WebMD Aetna participating Doctors and Hospitals are independent providers and are neither agents nor employees of Aetna. Contact 800.XXX.XXXX for assistance in locating an In-Network Provider. Printed: Call 800.XXX.XXXX or visit for inquiries regarding eligibility, claims, and plan benefits. Precertification Required. Call Medical Management at 800.XXX.XXXX Healthy Directions Network INDEX #: 009 6

7 Convenient Tools and Resources Your personalized member website Once enrolled as a member, you will have access to the Member Portal. When you log in, you ll find everything you need to know about your benefits from eligibility, to enrollment, to what s covered. It s another way we re working with you to help you get the most from your benefits so you can live a life that s balanced and informed. Registra on for the member website is easy If you re already registered to access your online account, simply enter into your browser and login from the homepage. If you re not yet registered, it s OK. Registra on is an easy three-step process. 1. Go to Then, in the top right corner, click Register. 2. Next, select Member under I am a and enter your group ID. You can find your group ID on the front of your member ID Card. (If you are new to the plan, you will soon receive your member ID Card in the mail.) Then, click Con nue. Please note: you may set up a login for yourself, as well as any children under age 18 who are covered by your plan. For privacy purposes, your spouse and dependents over the age of 18, covered by the plan, must each establish logins to access their individual informa on. 3. You will need to fill in your: Group ID (located on your member ID Card) Member ID (located on your member ID Card) Date of birth Name ZIP code address A username will be provided to you. A er you create a password and confirm your address you re done! You ll automa cally be logged into your new Meritain.com account. The next me you log in, just use the same username and password from Step 3. Members have the right to ask their health plan to place restric ons on (i) the way the health plan uses or discloses their PHI for treatment, payment or healthcare opera ons; and (ii) the health plan s disclosure of their PHI to persons who may be involved in their healthcare or payment thereof (e.g., family members, close friends). Important plan contacts What do you need help with? My medical benefits Customer Service The Aetna Choice POS II provider network and Wesley Preferred provider network Aetna provider line Precertification Medical Management Teladoc hour access to registered nurses 24x7 Nurse Line My prescription drug benefits Maxor Plus Rx Customer Service Mail Order Specialty Pharmacy Delta Dental EyeMed My enrollment or benefit elections 7

8 Notes 8

9 Your DocFind Online Directory Aetna Choice Point of Service (POS) II It s easy to find doctors and hospitals in your network When you and your family need care, you can look for doctors and hospitals in the Aetna Choice POS II network. It s easy when you use the online DocFind directory from Aetna.* With up-to-date listings, you can search for providers by name, specialty, gender, hospital affiliations and more. Find Aetna providers online in just a few quick steps You can use the DocFind directory anywhere you have Internet access. Just: 1. Visit 2. Key in the type of provider or provider name, specialty, procedure or condition under Who or what are you looking for? and the desired geographical area under Where?. Click Search. 3. Choose Aetna Choice POS II (Open Access) under Select a Plan. OR 4. Click on one of the options listed under Provider Types, Conditions or Procedures. You will be prompted to key in the desired geographical area and select your plan (as shown in step three). 5. Choose your provider from the list of providers displayed on the results screen. You can learn more about each by clicking on the provider s name. 6. Narrow your search results by using the filters under Narrow Your Results. Choices include Hospital Affiliations, Group Affiliations, Languages, Gender and Specialty. 7. For more search tips, you can click on Search Tips and FAQs on the home screen. If you have questions while searching for a doctor or hospital, simply click on the Contact DocFind link. It s at the top of any DocFind page. You ll be able to send a quick comment or question. Find providers by phone Need a provider when you re not near a computer? No problem. Simply call the Aetna Provider Line at from 8:00 a.m. 9:00 p.m. ET, Monday through Friday. If you need more information, we re here to help. Just call using the number on your member ID Card. *Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates. Providers are independent contractors and are not agents of Aetna or. Provider participation may change without notice. Neither Aetna nor provides care or guarantees access to health services. Information is believed to be accurate as of the production date; however, it is subject to change , Inc. All rights reserved.

10 Go In-Network and Save On Your Lab Costs There s an easy way to save money on your healthcare expenses, and it s one you might not even think about: getting lab work done in network. With your health plan, you may save big on lab services just by getting all of your testing done at an in-network lab. That s because many labs, doctors and other healthcare providers in the network agree to provide services at reduced rates for members. This helps you save. Two ways to make sure you save Here s what you need to do to make sure you save every time you need lab work: Is your doctor collecting your sample in the office? Just ask that it be sent to a participating lab. Is your doctor sending you to a lab for the testing? Ask for a lab requisition form to an in-network lab. This lets you go to a lab in your network. Find an in-network lab You can use the DocFind directory anywhere you have Internet access. Just: 1. Visit 2. Then, type in the type of provider or provider name under Who or what are you looking for? (for example, you could type in Quest here when looking for an in-network lab) and the desired geographical area under Where?. Then, click Search. 3. Choose Aetna Choice POS II (Open Access) under Select a Plan. OR For even more advantages Quest Diagnostics is a preferred network lab that offers you other advantages. Convenience. Visit Quest Diagnostics at for online appointment scheduling. Lower prices. Lower your out-of-pocket costs and keep your money where it belongs in your pocket. Nearby locations. With thousands of locations nationwide, you can find one close to your job, home or doctor s office. Skilled staff. Locations are staffed with professionals to help you with all your lab needs. Reminders. You get reminders to help you stay on top of your appointments. 4. Click on Labs and Diagnostic Center and then Laboratory [including Quest Diagnostics] under the Provider Types, Conditions or Procedures section. You ll be prompted to key in the desired geographical area and select your plan (as shown in step three). 5. Then simply choose your preferred lab from the list of in-network labs displayed on the results screen. You can learn more about each by clicking on the lab s name. If you have any questions, or need any help finding an in-network lab or doctor, just call Meritain Health Customer Service at the number on the back of your ID Card , Inc. All rights reserved.

11 Maternity Management A Balanced Beginning for You and Your Baby Congratulations on your pregnancy! Your employer cares about your pregnancy and getting you and your baby off to a healthy start. This is the goal of s proactive pregnancy and maternity management program. From your first trimester of pregnancy through post-delivery, your maternity management program will help you prepare for the events that will happen during your pregnancy. By joining the maternity management program, you ll better understand how to create a healthy start for your new baby. Your personal maternity nurse specialist Through the maternity management program, you ll be assigned your own maternity nurse specialist. Your nurse specialist, an experienced RN, will monitor your progress. You ll be able to work with your nurse specialist to learn more about your baby s health and wellness. You can also get answers to your questions and concerns. Your nurse specialist can help you follow your doctor s plan for your care and will tailor coaching to your unique needs. Questions? If you have questions about maternity management, we can help. Just call at , and dial option , Inc. All rights reserved.

12 My Health, My Time, mymeritain Did you know you can find a variety of healthcare tools and resources at Your member website, mymeritain, gives you 24-hour access to a number of tools and resources that can help you manage your health benefits. With mymeritain you can: Check your eligibility and benefits. Find the status of claims. View your Explanations of Benefits (EOBs). Review your benefit plan document. Access to mymeritain is as easy as If you have an account simply log in. If you re a new user, you ll need to register with these simple steps. Step 1 Step 2 From your computer, simply open your Web browser and go to Then, in the top right corner, click Register. Next, select Member under I am a and enter your group ID. You can find your group ID on the front of your member ID Card. (If you are new to the plan, you will soon receive your member ID Card in the mail.) Then, click Continue. Please note: you may set up a login for yourself, as well as any children under age 18 who are covered by your plan. For privacy purposes, your spouse and dependents over the age of 18, covered by the plan, must each establish logins to access their individual information. Step 3 You ll need to enter the following information, then select Submit: Member ID (located on your member ID Card) First name (employee, spouse or dependent) Zip code Date of birth (mm/dd/yyyy) Group ID (located on your member ID Card) Last name (employee, spouse or dependent) (personal address) A username will be provided to you. After you create a password and confirm your address you re done! You ll automatically be logged into your new mymeritain account. The next time you log in, just use the same username and password from Step 3.

13 Important information about mymeritain Spouses and dependents Per the HIPAA Privacy Regulations, spouses and dependents over age 18 have partially protected healthcare information. To access their information, they ll need to register for their mymeritain account using the previous steps. You can view financial information for all dependents, regardless of age. Returning user login When returning to the website after your account has been created, just enter your established username and password in the login box. Incorrect login You can click Home to return to the home page and try again if you receive an incorrect login message. Website support If you need help with the login process or forgot your username or password, we re here to help. You can contact customer service using the phone number printed on your ID Card. Website options Simply click the name of each function in the top banner of mymeritain to access the following options. Click Home to return to the welcome page. Healthcare Plan Overview You can view deductibles and out-of-pocket maximums by clicking on Healthcare Plan Overview. Claim Information Just click Claim Information to view your claims. The Quick Search button lets you view all claims. Claims with statuses of received, in review, processed or void will be displayed. You can view and print the Explanation of Benefits (EOBs) by clicking the link under the claim number. Cost Information For links to cost comparison tools, simply click Cost Information. Doctors and Hospitals It s easy to find a doctor on mymeritain just click Doctors And Hospitals. You ll be able to find providers by zip code (this includes all providers, not network specific). To search for in-network providers, you can click on Find A Doctor Or Hospital In Your Network (Aetna network only). Access My Health Tools For quick access to health and wellness links, coaching, personal health records, prescription drug information, telemedicine and more, you should click Access My Health Tools. (Options vary based on available benefits.) My Benefits You can click My Benefits to display some of the key features regarding your benefit plan, including prescription plan information, ID Cards and plan documents. Flexible Spending Account (if applicable) To access your flexible spending account information, you can click on the Flex Account link. Other Functions The following two functions are shown at the bottom of the page. Just click on the name of the function to access your information. User Documentation To view the member portal reference guide for more information on available features, just click the User Documentation link. Change User Information You can click Change User Information to change your password or to store your address. You can click Home at any time to return to the welcome page. If you need help navigating or registering your mymeritain account, you can call us at the number located on your ID Card , Inc. All rights reserved.

14 On Your Mark, Get Set, Go Meritain.com! Did you know? You have access to a variety of online tools and resources through What you ll find on the Member Portal Using the Member Portal, you have 24-hour access to a number of tools and resources that can help you manage your health benefits. Below are a few of the tools available on Meritain.com: Verify eligibility and benefits coverage Find the status of claims View your Explanation of Benefits (EOB) documents Review your benefit plan documents in their entirety View deductibles and out-of-pocket limits Submit Coordination of Benefits (COB) information Request Letter of Coverage (LOC) Update account settings Access as easy as 1 2 3! Step 1: You should open your Web browser and go to Step 2: You ll need to register your account. Start by clicking Register and then clicking on the Member tab. Your spouse and adult dependents will need to create their own accounts. Step 3: You ll need to fill in your: Group ID (you can find this on your ID Card). Member ID (you can find this on your ID Card, as well. You should enter it with no spaces or dashes). Date of birth. Name. ZIP code. You will be prompted to enter an address, create a username and password, and select a security question. Review the terms and conditions, and click I agree to terms and conditions and Next, or click Cancel. The next time you log in, just use the same username and password from Step 3.

15 On-the-go access to your benefits You can get benefits information when and where you need it right from your smart phones and tablets. Easy to access and easy to use 1. First, simply register for your mobile account through (If you ve already registered to access your personal information on the Member Portal you can skip this step. Then, simply log in to Meritain.com through the browser on your smart device to access your account.) * 2. From any mobile device, just log into Meritain.com. You ll find quick-to-navigate displays you can easily use with your device s touch screen. * For ease of navigation, we recommend you register for your account using a desktop computer. If you have any questions about how to register or use Meritain.com, we can help. Simply call our Customer Service department using the phone number on your member ID Card. Helpful benefits information You can rely on Meritain.com if: You need to quickly find a doctor or hospital in your network. You re not near a computer and need to know your deductible or out-of-pocket amounts. You want to research a claim or take a look at an EOB statement on the go. You want to download and view (.pdf) a copy of your ID Card. You may not always be in front of your computer. But now, you ll always be able to find the healthcare information you need to help you get the most out of your healthcare benefits. It is one more way is working hard to help you be your healthiest self , Inc. All rights reserved. Advocates for Healthier Living provides easy-to-use healthcare benefits you can use to stay healthy and produc ve. Contact us at the number on your ID Card if you have any ques ons about your plan.

16 Your 24x7 Nurse Line Program What is the 24x7 Nurse Line? You can reach the Nurse Line 24 hours a day, seven days a week for your health-related questions. You and your family can get health information or medical advice. You can also talk directly with a Registered Nurse (RN), or listen to recorded health topics. The RN can help you choose the best care for you, or suggest self-care techniques or over-the-counter medication. How does the 24x7 Nurse Line work? Speak with an RN. The 24x7 Nurse Line is staffed by specially trained RNs who can answer your questions about a current illness, discuss alternative treatments for health conditions, and help you make healthy lifestyle choices. Keep this number handy! s 24x7 Nurse Line: Use the improved Health Information Library. When you visit the recently enhanced Health Information Library, you can find over 1,000 health and wellness topics using voice activation! Simply state the topic you d like to learn about, and you ll hear a recorded message on the topic you have chosen. When should I call? You can call the 24x7 Nurse Line any time you have a question. The RNs can answer questions like: It s 2:00 a.m. and my son has a high fever and a sore throat. Should I take him to the emergency room? I just sprained my wrist. Should I have an X-ray? I ve heard about a new drug for weight loss. Could it help me? My doctor said I need to have surgery. What are my alternatives? You can speak with an RN by calling the 24x7 Nurse Line at If you have any questions, just call using the phone number on your member ID Card , Inc. All rights reserved.

17 Precertification Key To Your Good Health You can help make sure you and your family get quality healthcare when and where you need it. s Medical Management program is designed to ensure that you and your eligible dependents receive the right healthcare while avoiding unnecessary costs. It s easy to precertify Your provider will often handle your precertification, but as an active participant in your healthcare, you can call us to begin the process. To precertify care, you ll need to call the phone number on your ID Card and provide information about the patient, the provider and the procedure. A special medical management team will then review your treatment plan. Your team will help make sure you re getting the right care, in the right setting for the right length of time. You may need to call to precertify the following: Prior to elec ve or non-emergency admission to a hospital. Within 48 hours (or two working days) following an emergency admission to hospital. Prior to having certain elec ve diagnos c treatments specified in your plan booklet. Prior to hospice admission. When you need to obtain home healthcare. Before certain diagnos c procedures. You can verify the services that require precertification in your health plan booklet. You can also call customer service using the number on the back of your ID card. It s important to remember that if we do not receive your precertification, you may have extra financial responsibility for your healthcare services , Inc. All rights reserved. You have a right to appeal If you or your doctor aren t satisfied with the decision of the medical management team, you have a right to appeal this outcome. You can find steps for the appeal process in your health plan booklet. If you have any questions about precertification, we can help. Simply call using the phone number on your ID Card. This material is being provided as an informational tool. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this publication and any attachments, is not exercising discretionary authority over the plan and is not assuming a plan fiduciary role, nor is providing legal advice. Advocates for Healthier Living provides easy-to-use healthcare benefits you can use to stay healthy and produc ve. Contact us at the number on your ID Card if you have any ques ons about your plan.

18 Accessing Other Insurance Coverage Online Your healthcare benefits plan includes a provision called coordination of benefits. This means if one person is covered by two benefit plans, both plans share responsibility for covering that person s healthcare expenses. This helps prevent duplicate payments and helps hold down healthcare costs. Examples of other coverage include: Medicare (due to age or disability), group coverage through a family member s employer, association coverage through a group you or a family member belongs to, student health coverage, or coverage mandated by a divorce decree. may sometimes ask you to update this information so we can keep our records current. Once you have registered on the Member portal at you can complete your Coordina on of Benefits (COB) online: 1. From the Benefits and Coverage dropdown, select Coordina on of Benefits. 2. You ll be asked if you or any dependents have other coverage, other Medicare coverage and/or other Medicaid coverage. Simply answer Yes or No to report if you or anyone in your family has other health coverage. 3. If you answer Yes, you ll be asked for informa on about the other coverage like start date, carrier name, policy holder name and date of birth, etc. Just fill out the forms that open when you select Yes. 4. A er you complete the form, click Next to see a summary of the informa on , Inc. All rights reserved. 5. If you agree with the summary, click Submit in the bo om right corner. If you need to make changes, click Edit at the top of the summary. If you have any questions, you can call Customer Service at the number on the back of your ID Card for assistance. Please note: Failure to update coordina on of benefits Other will COB result options in claims being are denied. available For your convenience, please visit h ps:\\www. meritain.com/tools-resources/formsearch for a copy of the Other Insurance Coverage Form. You can it to: Forms.Direct@meritain.com Or you can mail it to: Eligibility Department P.O. Box Minneapolis, MN Or fax to You should keep a copy of the fax confirmation record if you plan to call to confirm receipt. Advocates for Healthier Living provides easy-to-use healthcare benefits you can use to stay healthy and produc ve. Contact us at the number on your ID Card if you have any ques ons about your plan.

19 Other Insurance Coverage Information Welcomes You! To help us properly handle any existing or future claims, please tell us about any other healthcare coverage you and/or your dependents may have. Examples include another group plan, an individual policy, COBRA, Medicare, Medicaid, state programs, Social Security benefits due to a disability, or medical expenses covered by another person due to a court order/decree. If we do not receive this information, it may delay the processing and payment of your claims. DO YOU OR ANY OF YOUR DEPENDENTS HAVE OTHER COVERAGE IN EFFECT AT THIS TIME? YES NO Complete and return to: Eligibility Department P.O. Box Minneapolis, MN Fax: Forms.Direct@meritain.com PLEASE PRINT: EMPLOYEE NAME NAME OF COMPANY (YOUR EMPLOYER): USD 259 WICHITA PUBLIC SCHOOLS MEMBER ID NUMBER EMPLOYEE DOB GROUP NUMBER COMPANY / PROGRAM NUMBER 1 NAME OF INSURANCE COMPANY DATE OF BIRTH (POLICY HOLDER) PLEASE LIST ALL FAMILY MEMBERS COVERED BY THIS PLAN NAME OF POLICY HOLDER EFFECTIVE DATE OF COVERAGE RELATION TO POLICY HOLDER WHAT TYPE OF COVERAGE IS THIS? MEDICAL COMPANY / PROGRAM NUMBER 2 NAME OF INSURANCE COMPANY DATE OF BIRTH PLEASE LIST ALL FAMILY MEMBERS COVERED BY THIS PLAN NAME OF POLICY HOLDER EFFECTIVE DATE OF COVERAGE RELATION TO POLICY HOLDER WHAT TYPE OF COVERAGE IS THIS? MEDICAL MEDICARE NAME OF PERSON COVERED BY MEDICARE MEDICARE ID NUMBER: REASON FOR MEDICARE ELIGIBILITY: OVER AGE 65 TOTAL DISABILITY END-STAGE RENAL DISEASE (provide dialysis date) PART A EFFECTIVE DATE(S) PART B EFFECTIVE DATE(S) PART D EFFECTIVE DATE(S) COURT ORDER OR DECREE COVERED INDIVIDUALS NAME OF PARENT(S) WITH LEGAL CUSTODY OF CHILDREN EFFECTIVE DATE ADDRESS OF PARENT(S) WITH LEGAL CUSTODY FAILURE TO PROVIDE THIS INFORMATION WILL RESULT IN DENIAL OF CLAIMS SUBMITTED BY YOU AND YOUR FAMILY MEMBERS.