Transcript Slide 1

PASADENA ISD AND AETNA
EFFECTIVE JANUARY 1, 2012
Page 1
Pasadena ISD – Aetna Plan Comparisons
PLAN FEATURES
Network
Aetna HealthFund
Choice CPOSII Plan
(Plan II)
Choice POSII Plan
(Plan I)
In-Network
Out-Network*
HealthFund Amount contributed by
Pasadena ISD
Plan Coinsurance
In-Network
Out-Network*
$500 Employee
$1,000 EE+S, Ch, F
50%
20%
50%
$1,500 per person
$4,500 per family
$2,500 per person
$7,500 per family
$7,500 per person
$22,500 per
family
$3,500 per person
$10,500 family
$10,500 per person
$31,500 family
$5,000 per person
$15,000 family
Lifetime Maximum Benefit
Unlimited
Unlimited
Unlimited
Unlimited
Primary Care Physician (PCP) Office Visits
$25 copay
50% after ded
20% after ded
50% after ded
Specialty Care Office Visits
$35 copay
50% after ded
20% after ded
50% after ded
100%
50% after ded
100%
50% after ded
PCP or Specialist copay
50% after ded
100% ded waived
50% after ded
100%
50% after ded
100% ded waived
50% after ded
20% after ded
50% after ded
20% after ded
50% after ded
Calendar Year Deductible
Individual
Family
Out-of-Pocket Maximum
Individual
Family
Preventive Care Annual routine physical:Adult
and Well Child, GYN, Mammograms,
Colorectal Cancer Screenings,PSA Tests
Diagnostic Outpatient Lab/
X-rays/Testing (part of office visit)
Diagnostic Outpatient Lab/
X-rays/Testing (Facility)
Complex Imaging Services
20%
$500 per person
$1,500 per family
$15,000 per
person
$45,000family
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Pasadena ISD – Aetna Plan Comparisons cont’d
PLAN FEATURES
Network
Inpatient Hospital Services
Outpatient Surgery
Choice POSII Plan
In-Network
$500 per confinement copay,
then 20% after ded
Choice POSII Plan
Out-Network*
$500 per confinement
copay, then 50% after
ded
Aetna HealthFund
Choice CPOSII Plan
Aetna HealthFund
Choice CPOSII
Plan
In-Network
Out-Network*
20% after ded
50% after ded
20% after ded
50% after ded
20% after ded
50% after ded
$250 copay, then 20% after
ded
same as preferred care
$250 copay, then 20%
after ded
same as preferred care
20% after ded
same as preferred care
20% after ded
same as preferred care
Urgent Care Copay/Coinsurance
(Copay waived if admitted)
$50 copay
50% after ded
20% after ded
50% after ded
Walk In Clinics
$25 copay
50% after ded
20% after ded
50% after ded
Emergency Room Copay/Coinsurance
(Copay waived if admitted)
Ambulance
*Out of Network benefits are paid at the
Limited Fee Schedule
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Out-of-Network Limited Benefit Payment Schedule
• Pasadena ISD has a Limited Out-of-Network benefit payment schedule. When you need medical
care, your Aetna health benefits plan gives you and your participating physician a choice. Advise your
participating physician that it is important to you that the highest level of benefit coverage is desired by
ensuring to you that they refer you to only in network facilities and providers with Aetna.
• Limits on authorized costs associated with Out-of-Network facilities/providers. To help curb excessive
out-of-network facility/provider costs, Pasadena ISD has established a Limited Out-of-Network fee
schedule that limits the Plan’s exposure to the market rate for non-emergency services and
procedures. If you use an out-of-network facility or provider, you will be responsible for paying the
difference between the covered amount (which is based on established rates for our geographic area)
and the amount the facility charges. If you incur these expenses, they will not apply to your coinsurance
maximum.
• When you use a Network provider, you are protected from charges that are greater than the "allowed"
amount. However, when you use an out-of-network provider, you may have to pay for any of the
charges that are greater than the "allowed" amount in addition to your coinsurance and deductible.
• All out-of-network provider and facility types will be included in the Limited Out-of Network benefit
reimbursement. Examples include, but are not limited to: hospitals, ambulatory surgery centers,
physicians, pathology laboratories, radiology centers, psychologists, master social workers, physical
therapists, certified nurse anesthetists, outpatient dialysis, radiology, laboratory, sleep lab, MRI/CT etc.
• NOTE: It is your responsibility to make sure your physician, facility or hospital is in-network or
you will pay out-of-network costs. You can help keep costs down by using network providers.
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Your Personal Website – Aetna Navigator
Your easy to use Online Resource
• How to use Aetna.com/Navigator program – Go to www.aetna.com
–
Register just like you would register for your on-line banking or other sites.
• Doc Find - a complete listing of Aetna participating providers. Select your provider category.
You can search by city, state, zip, specialty, hospital affiliation, provider name, gender,
language and education. Select the “CPOSII Open Access” network
• Estimate the Cost of Care – get estimates for what you will pay for visits to doctors or common
procedures
• View Deductible and Plan Limits – review amounts applied to your individual and family
deductibles and out-of-pocket maximums
• View Explanation of Benefits – review portion of claims paid by the plan and the amount you
must pay
• Take a Health Assessment – Take your Simple Steps personal health risk assessment
• Aetna Life Essentials – discount programs for vision care, hearing aids, fitness, etc
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Aetna Health Connections – Disease Management
CONFIDENTIAL PROGRAM!!!
Aetna program designed to help you or your
eligible family member(s) learn more about your
condition and work closely with your doctor to
improve your health and quality of life.
Educational information is provided and for high
risk members, access to a registered nurse
“Health Coach” is offered. The adjacent list
includes a few of the 35 conditions managed by
this program. To learn more about Disease
Management, login to www.aetna.com
• If you receive a call or letter from Aetna please
return their call or contact them as requested.
All information is confidential with Aetna and
is not shared with Pasadena ISD.
• If you have one of the conditions listed or think
you are at risk for one of these conditions, you
can volunteer into the program by calling
1-866-269-4500 OR make an appointment to
discuss with the Aetna on-site nurse.
Asthma
Back Pain
Cancer
Cerebrovascular
Disease
Chronic Heart Failure
Chronic Obstructive
Pulmonary Disease
Coronary Artery Disease
Cystic Fibrosis
Depression
Diabetes
Digestive
HIV
Hepatitis
Hypertension
Inflammatory
Bowel Disease
Kidney Failure
Peripheral Artery
Disease
Rheumatoid
Arthritis
Sickle Cell
Anemia
Weight
Management
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Simple Steps Program
Your Health Risk Assessment – CONFIDENTIAL!
• Simple Steps To A Healthier Life is an interactive online health and wellness program that can
help you improve or maintain your health in ways that fit your lifestyle.
• You start by taking an online Health Assessment that will help identify some of your health
needs. Questions focus on health habits and family health history and all answers are kept
secure and confidential.
Note: It is best to have your current lab and biometric results to input into the assessment (Blood pressure, cardiac CRP,
total cholesterol, LDL and HDL cholesterol, triglycerides, and fasting glucose). However, even if you don’t have all of
these results - you can still complete your health assessment and fill these results in at a later date).
• Once your health needs are identified, you’ll receive easy-to-understand Health Reports and a
personal invite to join the program most likely to help meet your needs and an Action Plan that’s
just for you, suggesting a combination of Healthy Living Programs.
• Choose the programs, tools and information that are right for you. Each program includes
interactive tools to help you reach your health goals in a fun and interesting way. You can use
an online Fitness Planner, a Healthy Shopping List and more.
• Take the first step to healthier living. Visit www.simplestepslife.com. Be sure to complete or
update your health assessment at www.aetna.com! ALL information is confidential and
is not shared with Pasadena ISD!
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NEED MORE INFORMATION?
Aetna InteliHealth®
Aetna InteliHealth® is an exclusive resource that can be accessed
online (www.aetna.com) to find up-to-date health information and
resources including:
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Information on diseases & conditions
Articles on lifestyle improvement
Gender and age specific health issues
Medication information
Health assessments
Quizzes
Medical dictionary
Health calculators (BMI, etc.)
Current health research news
“How-to” slide shows
Email health updates
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Need questions answered FAST???
Call Aetna's Informed Health® Line
• Aetna's Informed Health® Line gives you easy access to credible health information. All Informed Health
Line services are available 24 hours a day, 365 days a year on demand from your touch-tone phone.
• If you prefer to view health information online, simply login to www.aetna.com and click on the link for
the Healthwise® Knowledgebase.
• 24 Hour NurseLine - Speak with a registered nurse who has experience in a variety of health topics at
any time of the day*.
• Audio Health Library - Phone in to choose from thousands of common health topics via recorded
messages.
Easily transfer to the Nurse Line for questions.
• Healthwise® Knowledgebase - Search for detailed information about health conditions, medical tests
and procedures, medications and treatment options at www.aetna.com.
• To reach the 24-Hour Nurse Line or Audio Health Library call 1-800-556-1555.
* Informed Health Line Nurses cannot diagnose, prescribe or give any medical advice. Contact your physician with any
questions or concerns regarding your health care needs.
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Choosing A Plan that is Right for You
• Making the right plan choice can be a difficult decision. This decision should be based on
several things such as your personal medical condition and usage of services, financial
situation, and your level of comfort with coinsurance vs. copayments. The following
definitions may assist you in the decision-making process.
• Co-payment: the predetermined dollar amount you will pay for a service (Examples:
physician office visits, urgent care, emergency room, physical therapy, counseling).
• Coinsurance: percentage employee is responsible for paying up to a specific dollar
amount per calendar year (Covered services paid from 50-100% depending on the plan
selected and service rendered).
• Deductible: initial out-of-pocket costs that must be paid before the plan begins to pay
benefits (Either $500 or $2,500 based on plan elected).
• Your Aetna Choice POS II Plans do not require you to select a network primary care
physician (PCP), although selecting a PCP is encouraged. These plans also allow you to
self-refer to a specialist. Your choice of provider dictates the amount you will pay in
copayments, coinsurance and/or deductibles.
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PASADENA AREA URGENT CARE FACILITIES
Immediate Medical Care Group
Pasadena Community Health
6825 Spencer Hwy
Pasadena, TX 77505
(281) 335-0606
4002 Burke Road
Pasadena, TX 77504
(281) 606-2020
Concentra Health Services, Inc.
125 East 8th St
Deer Park, TX 77536
(281) 930-8555
NOTE: It is your responsibility to make sure your physician, facility or
hospital is in-network or you will pay out-of-network costs. You can help
keep costs down by using network providers.
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PASADENA AREA WALK IN CLINICS
H-E-B - RCMH, LLC dba RediClinic
6210 Fairmont Pkwy.
Pasadena, TX 77505
(866) 607-7334
MinuteClinic Diagnostic of Texas, LLC
CVS Pharmacy – 2900 Broadway St.
Pearland, TX 77581
(866) 389-2727
Take Care Health Texas, P.C.
Walgreens- 8430 Broadway St.
Pearland, TX 77584
(866) 825-3227
H-E-B - RCMH, LLC dba RediClinic
2955 Gulf Freeway South
League City, TX 77573
(866) 607-7334
H-E-B - RCMH, LLC dba RediClinic
701 West Parkwood
Friendswood, TX 77546
(866) 607-7334
NOTE: It is your responsibility to make sure your physician, facility or hospital is in-network or
you will pay out-of-network costs. You can help keep costs down by using network providers.
When utilizing these clinics, regular plan will provisions apply
(ie; copays, deductibles and out of pocket limits).
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Need More Information?
• Aetna on-site Contact:
(until December 16, 2012)
• Deaneva Taylor
• 713-740-0105
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What is the Cost to the Employee?
• Choice POSII Plan Rates (Plan 1)
Employee’s Cost
• Employee
$170.00
• +Spouse
$500.00
• +Child (Children)
$400.00
• +Family
$725.00
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What is the Cost to the Employee?
• Aetna Health Fund (Plan2)
Employee’s Cost
• Employee
$ 70.00
• + Spouse
$210.00
• + Child (Children)
$175.00
• + Family
$350.00
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