Q. What are the basic features of the RMP POS II options?
A. The basic features of the RMP POS II options are:
- The Plan generally covers only medically necessary care and services.
- Inpatient hospital stays must be pre-certified for maximum benefit allowed by the Plan.
- The Medical POS II network of participating providers offers you savings in both time and money.
- Preventive care provisions help you stay healthy.
- The Plan offers you the opportunity to have your benefits determined before a procedure is performed.
Both RMP POS II options include the features listed below.
Expenses are covered under these options only if they are medically necessary. Care is medically necessary if it is a therapeutic procedure, service or supply used in the medical treatment of an injury, disease, or pregnancy, which is generally recognized by the United States medical community as appropriate. Claims are reviewed as submitted, and some or all of any claim or series of services could be denied as not being medically necessary. It also means that experimental or investigational procedures, drugs, devices or biological products not proven by long-term clinical studies are generally not covered. See Exclusions for limited exceptions.
When determining medical necessity, the Administrator-Benefits may consider the Clinical Policy Bulletins (CPBs) published by Aetna, the claims administrator. CPBs are based on established, nationally accepted governmental and/or professional society recommendations, as well as other recognized sources. These CPBs may be found on the Aetna website at www.aetna.com or the Aetna NavigatorTM website at www.aetnanavigator.com.
Pre-certification is a mandatory review of inpatient admissions and select ambulatory procedures and services in advance of treatment, to confirm medical necessity based on clinical criteria and benefits eligible under the Plan. If you are using a network provider, the provider will perform the precertification process on your behalf. If you are using a non-network provider, you must initiate the precertification process yourself. Failure to obtain a required precertification for non-network hospitalization services will result in a $500 penalty, even if the services are medically necessary and otherwise covered under the Plan. For more information on precertification, see the National Precertification List on the Aetna member website.
The following outlines a few examples of services that need to be pre-certified. If you are unsure if the service you are seeking requires pre-certification, call Aetna Member Services.
For non-emergency medical care:
- If you are using POS II network provider, or a mental health PPO network provider, your provider will handle the pre-certification process for you.
- Before you are admitted to a hospital that does not participate in the POS II or mental health PPO network, you must call Aetna for a medical pre-admission review or Magellan for a mental health confinement. This is required for most inpatient admissions, including extended-care facilities.
- You are not required to call to pre-certify:
- Hospitalization outside the United States, for both medical and mental health or substance abuse;
- Hospice care.
- Extended care facility.
- Skilled nursing care.
- Private duty nursing.
- Defibrillators and pacemakers not a result of emergency treatment.
- Heart catheterizations.
- Facility-based sleep studies.
- Cardiac rhythm implantable devices.
- Comprehensive infertility services and Advanced Reproductive Technologies (ART), including in-vitro fertilization (IVF), gamete intra-fallopian transfer (GIFT), zygote intra-fallopian transfer (ZIFT) and frozen embryo transfer (FET) only if obtained at an Aetna-designated Institute of Excellence.
Enhanced clinical review
The Plan also includes a utilization management program, known as Enhanced Clinical Review, of some diagnostic services (e.g., MRIs, CT Scans, Cardiac Imaging, sleep studies, hip/knee replacement procedures, etc.).
An enhanced clinical review is a mandatory review of select covered services that have equivalent, lower-cost alternatives, to ensure the higher cost service is medically necessary in advance of treatment. If the review is not completed and the treatment is not approved in advance, it will not be covered under the plan.
Please contact Aetna Member Services to determine if the service your physician has recommended requires enhanced clinical review.
For emergency inpatient admissions:
Certification must be made within 48 hours following an emergency inpatient admission. If the admission is on a weekend or holiday, notification must be made within 72 hours.
- If you are using POS II network provider, your provider will obtain certification for you.
- You or someone acting on your behalf must call to certify care if you are in a non-network or out-of-network area hospital.
For mental health or substance abuse care:
You should call Magellan Behavioral Health for pre-certification of any mental health or substance abuse care. This applies whether you are inside or outside the United States.
The Aetna POS II network is not used for mental health or substance abuse care. Contact Magellan for network information and pre-certification of mental health or substance abuse care. See the Information sources section.
If you require mental health or substance abuse care in conjunction with a medical emergency, notify Magellan.
For certain prescription drugs:
You must call Express Scripts for pre-certification of certain prescription drugs. This applies whether you are inside or outside the United States.
In some cases, you may be required to try one or more specified drugs to treat a particular medical condition before the plan will cover another (usually more expensive) drug.
Additionally, as part of Express Scripts’ Advanced Utilization Management (AUM) program, certain targeted drugs will not be covered unless pre-certified by Express Scripts, based on medical evidence submitted by your physician.
Non-targeted drugs are covered without precertification or prior authorization. Refer to the Prescription drug program section for more details.
A pre-determination is an estimate of covered services and benefits payable in advance of treatment. It is not a guarantee of benefits eligible or payment amount. You may request a predetermination for any covered service. In most cases, you may receive an answer over the phone. In other cases, information from your provider may be needed. You or your doctor can also request a pre-determination of benefits, in writing, before the service is performed.
Pre-determination is recommended for all outpatient surgical procedures. This pre-determination may require review by one or more doctors. Be sure to allow time for this review between the pre-determination request and the proposed date of the service. By obtaining the written response, you will have more detailed information about the level of reimbursement.
For more information on requesting a predetermination, see the Information sources section at the front of this SPD.
When you call for a benefit pre-determination, be ready to provide the following information:
- Primary participant's name and member ID, which can be found on your Aetna ID card;
- Patient's name;
- Complete description of medical services or surgical procedures. If possible, include the diagnosis code(s) and the five-digit Current Procedural Terminology (CPT) codes or the Healthcare Common Procedure Coding System (HCPCS) alpha-numeric codes, which you can get from the provider;
- Provider's complete information including name, address, phone number, and zip code;
- Provider's proposed fee for each service.
Federal law mandates that benefit programs such as the Retiree Medical Plan cover eligible participants for a minimum length of stay for delivery and newborn hospitalizations. Those minimums are 48 hours following a vaginal delivery and 96 hours following a Cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable).
Because the Plan is Grandfathered, the Plan does not provide breastfeeding support, counseling and equipment for the duration of breastfeeding.
POS II network
The network includes a group of physicians, hospitals, and other providers who have met standards for licensing, academic background and service. If you use network providers, the Plan pays a larger portion of the covered expenses. Network providers have agreed to negotiated charges which may save you and the plan money. Other advantages to using Medical POS II network providers for medical care are:
- Most office visits, diagnostic laboratory and X-ray work are reimbursed at 100%, unless related to surgery or emergency.
- Emergency room physician expenses, in-patient hospital, outpatient surgery or complex surgery are subject to deductible and coinsurance.
- Other expenses such as home health care, durable medical equipment or complex imaging are reimbursed at the network reimbursement level (either 80% for the POS II "B" or 75% for the POS II "A") of a negotiated rate after you meet the annual deductible.
- Your annual out-of-pocket maximum is significantly lower.
- Retiree Medical POS II network providers file claims and handle the hospital pre-admission review process for you.
- All negotiated charges are within reasonable and customary limits.
Anyone in the RMP POS II "A" or "B" option may receive network benefits by using Aetna Choice®POS II network providers.
POS II networks are located throughout the United States. As explained in the Introduction, the Medical POS II is part of the Aetna Choice® POS II network.
You are a network participant if you live in a POS II area. These are some of the Retiree Medical POS II areas:
- Beaumont, Texas
- Baton Rouge, Louisiana
- Dallas, Texas
- Houston, Texas
If you or an eligible family member resides in a network area, you can use Aetna's Internet DocFind® (www.aetna.com/docfind) to locate providers in the area.
Benefits based on the network status of the provider
Generally, you will receive network benefits only if the provider is in the POS II network. This applies whether or not the care is received in a network area or in an out-of-network area.
To find an Aetna Choice® POS II provider:
- Check DocFind® (www.aetna.com/docfind) on Aetna's website for the most up-to-date list of Choice® POS II providers. The site is updated six times a week, excluding holidays, Sundays or during interruptions due to system maintenance, upgrades or unplanned outages. Before your appointment, confirm with Aetna Member Services, DocFind®, or the doctor’s office whether the doctor participates in the network, because network participation may change.
- Call Aetna Member Services for help with locating a POS II network provider.
Co-Payment for office visits/lab work when provided by a primary care physician; higher co-payment when provided by a specialist.
When you use Retiree Medical POS II network providers for office visits, you are not subject to the annual deductible. You pay a co-payment for each office visit, including most related lab work and radiology performed by an RMP POS II network provider.
A co-payment does not apply to more extensive tests, including complex imaging (i.e., CT scans, MRI, MRA, PET/SPECT), radiopharmaceutical stress tests, angiography myelography, MUGA scans and sleep studies, which are subject to the deductible and co-insurance.
If an injection (other than an injection into a vein or artery) is received in a network doctor's office without an office visit, the co-payment will be the actual cost of the injection or the office visit co-payment, whichever is less. For infusion therapy and chemotherapy, a fixed co-payment only applies to the office visit. All other related services are paid at coinsurance. Allergy serum dispensed by a network doctor is reimbursed at coinsurance after the deductible.
These co-payments do not apply to your annual deductible but do apply to your annual out-of-pocket limit. See the explanation beginning in the Payment section for more information about deductibles and co-payments.
Is your doctor a network provider?
Call your doctor's office to confirm his or her participation in the Aetna Choice® POS II network. If your doctor is not participating, ask him or her to consider applying to participate. Your doctor can obtain information about becoming a network participant from Aetna's website (www.aetna.com/healthcare-professionals/index.html) or by calling Aetna Credentialing Customer Service at 1-800-353-1232.
If an Aetna Choice POS II network provider is not available within your access area, you may contact Aetna Member Services for information regarding the Plan's alternative network deficiency benefit. The alternate benefit is designed to address any network deficiency situations. Benefits will be paid at 80/75% of the Reasonable and Customary fee. Copayments do not apply.
Show your ID card
When you visit a physician or other health care provider, present your Retiree Medical Plan identification card. This helps the provider confirm your eligibility and understand your benefits coverage.
If you show your ID card to a network provider, the office staff should only ask you for your co-payment and any deductible amounts, not for full payment.
If you live in a POS II network area and do not use POS II network providers
When you use non-network providers:
- Your out-of-pocket costs will generally be higher. The Plan's reimbursement level is 60% for the POS II "B" and 55% for the POS II "A" of reasonable and customary charges, after you satisfy the deductible.
- You must call Aetna to initiate the medical pre-admission review process for inpatient treatment.
- If your provider's charges are above reasonable and customary limits, you are responsible for paying any amounts above reasonable and customary limits. You may be balance billed by the provider for any amount not reimbursed by Aetna.
- You are responsible for submitting claims.
Go to the nearest hospital for treatment. Benefits for emergency care (as a result of emergency outpatient treatment or an emergency admission to a hospital following emergency outpatient treatment received at the same hospital) are paid at the network reimbursement level for both network and non-network providers. However, the network reimbursement level for emergency care by non-network providers is only payable until the patient is determined able to be safely transferred to a network facility.
If you need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the world. Aetna has adopted the following definition of an emergency medical condition:
An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson (including the parent of a minor child or the guardian of a disabled individual), who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
- Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
- Serious impairment to bodily function; or
- Serious dysfunction of any bodily organ or part.
Some examples of emergencies are:
- Heart attack or suspected heart attack
- Uncontrolled or severe bleeding.
- Suspected overdose of medication.
- Severe burns.
- High fever (especially in infants).
- Loss of consciousness.
Some common examples of non-emergencies are:
- Ear Infections
- Colds and Flu
Reimbursement for Emergency Services
Reimbursement for emergency services from non-network providers are limited to reasonable and customary amounts, including services for radiology, pathology, anesthesiology, ambulance or emergency room physician services. In most instances, the provider will accept this reimbursement; however in the event you are billed for any balance, you may submit the balance to Aetna for additional processing. If you do so and you are enrolled in the automatic rollover process to the Health Care Flexible Spending Account (HCFSA), an overpayment from the HCFSA may result, and you should contact Aetna to discuss options to return the overpaid HCFSA funds back into the account.
When you go to the emergency room, you are subject to a deductible. If you are admitted as an inpatient to the hospital following emergency outpatient hospital treatment, the deductible amount will apply to your separate inpatient hospital deductible. See the Benefit summary.
Reimbursement for non-emergency services
If you go to a non-network emergency room and your condition is determined to be non-emergency, then the expense may be subject to the non-network level of reimbursement (either 60% for the POS II "B" or 55% for the POS II "A"), after the plan year deductible has been satisfied.
Your physician may direct you to an Urgent Care Center as an alternative to a hospital emergency room when he or she feels it is appropriate to do so. If you or a family member receive care at a network urgent care center, you will pay the applicable co-pay, equal to the specialist physician co-pay under your plan option, and the plan pays the remaining charges. If you live in a network area, and you use a non-network urgent care center, you will be reimbursed at the non-network level (either 60% for the POS II "B" or 55% for the POS II "A"), after the plan year deductible has been satisfied. If you live in an out of network area, you will be reimbursed at the out of network area level (either 80% for the POS II "B" or 75% for the POS II “A”) after you have met your deductible.
Care while traveling
For non-emergency care, call Aetna Member Services to identify a nearby POS II network provider or check DocFind® on Aetna‘s website (www.aetna.com/docfind).
If you live outside a retiree medical POS II network area
If you live outside a POS II network area, you are considered to be in an out-of-network area and you will be reimbursed at 80% for the POS II "B" and 75% for the POS II "A" of reasonable and customary charges when you use a non-network provider for services other than those listed under Emergency Care. In addition, you must satisfy the deductible for all covered services other than preventive care. You are responsible for initiating the medical pre-admission review process for inpatient treatment unless you use a network provider.
Even though you may not live in a POS II network area, you may live in or near locations where there are POS II providers. If you receive care from an Aetna Choice® POS II network provider — even while traveling — you will receive network reimbursement and network co-payments will apply.
If you incur claims outside of the U.S., reimbursement is paid at either 80% for the POS "B" or 75% for the "POS A" of billed charges after deductible. There is no reasonable and customary profiling for foreign providers.
If a covered family member lives away from home
If you live in a POS II network area and you have a covered family member who lives away from home (for instance, you have a child away at school), your family member's ZIP code determines the level of benefits the Plan pays.
Call Aetna Member Services with your family member's ZIP code to find out if Aetna has a Choice® POS II network in the area. If a network is there, you can contact Aetna Member Services or use the Internet DocFind to identify providers in the area. Here is how benefits are determined:
- If your family member receives care from a network provider, benefits will be paid at the network level.
- If your family member lives in a POS II network area but uses non-network providers, benefits are paid at the non-network level.
- If your family member lives in an area where the POS II network is not available and receives care from a non-network provider, benefits are paid at the out-of-network area level — regardless of whether you live in a network or non-network area — if you have notified Aetna of your family member's address.
Upon request, Aetna Member Services will provide an identification card for your family member.
Because the Plan is a Grandfathered Plan, only certain preventive care services will be covered at 100%. If you use a non-network provider or live in a location where there is not a POS II network, reasonable and customary charges for covered preventive care services will continue to apply. Preventive care services covered at 100% include the following:
- Routine Immunizations
- Prostate-Specific Antigen Test (PSA)
- Digital Rectal Examination (DRE)
- Routine Adult Physical
- Routine Mammography
- Routine GYN Exam
- Routine Well Baby Exam (includes hearing exam if under age 7)
- Routine Well Child Exam (includes hearing exam if under age 7)
- Colorectal Cancer Screening
- Double Barium Enema
- Fecal Occult
To receive preventive care benefits, the doctor's bill must indicate that the service is preventive in nature. If you are found to have a condition requiring additional treatment, the additional covered services will be paid after you meet any remaining annual deductible.