Frequently Asked Questions
What is included in the Medical Out-of-Pocket maximum? What is included in the Pharmacy Out- of-Pocket maximum? The Medical Out-of-Pocket maximum is the maximum amount a member must pay during the policy year for covered essential health benefits. The OOP includes a member’s deductible and any coinsurance member responsibility. The Pharmacy OOP includes only pharmacy co-pays. The Medical OOP does NOT include monthly premiums, or billing from out-of-network providers. What is an in-network vs out-of-network provider? Aetna contracts with a wide range of doctors, as well as specialists, hospitals, labs, radiology facilities and pharmacies. These are the providers that are considered “in your network”. Specifically, each of these providers has agreed to accept Aetna’s contracted rate for your medical care and services rendered. The contracted rate includes both Aetna’s share of the cost, and the member’s. Your share may be in the form of a co-payment, deductible, or co-insurance. For example, Aetna’s contracted rate for a primary care visit might be $125. The Plan has a $25 co-payment for the visit; the member will pay $25 of the cost and your insurance plan will pay the remaining $100. An “out-of-network” provider is a medical doctor or facility that is not in contract with Aetna. This means that the provider may charge members higher rates for medical services and care, outside of the standard “in-network” rates. For example, a out-of- network provider may charge $200 for a primary care visit. Aetna may pay an adjustment of an out-of-network benefit of $80 dollars to the provider, so the member may be balance-billed for the remaining $120 cost of the visit. When can I change my beneficiary information for my Basic Life Insurance? Any time! It is important that all beneficiary information be kept up-to-date. You may need to change it after a marriage, divorce, or birth of a child. You can go into Employee Navigator anytime to update your beneficiary.
Term
Definition
Network Office Visit (PCP) The “per visit” co-pay cost for a primary care or standard network doctor.
The “per visit” co-pay cost for a specialized doctor (cardiologist, OB/GYN,
Specialist Office Visit
orthopedic, gastrointestinal, etc.)
The amount of money a member owes for any In-network health care services before co-insurance coverage begins. These are generally services that are NOT covered under a standard co-pay (inpatient surgery, outpatient surgery, MRI, etc.) Deductibles run on a calendar year basis. After any applicable deductible is met, the remaining cost of any in-network health care service is divided between the insurance carrier and the member. A 70% / 30% network co-insurance would divide the cost of a service with 70% paid by the insurance carrier and 30% paid by the member. These are generally services that are NOT covered under a standard co-pay (inpatient surgery, outpatient surgery, MRI, etc.) The maximum amount a member must pay during the policy year for covered essential health benefits. The OOP includes a member’s deductible, any co-insurance member responsibility, primary care and specialist office visit co-pays, ER or Urgent Care co-pays, and prescription co-pays / costs. The OOP does NOT include monthly premiums, billing from out-of-network providers, or spending for non-essential health benefits. The cost of a one month supply of a prescription drug. All covered drugs are designated into tiered levels based on drug usage, cost, and clinical effectiveness. Tier 1 usually includes generics, while Tier 2 generally includes preferred brand name medications. Tier 3 typically includes non-preferred brand name medications, Tier 4 usually includes higher cost drugs and Specialty Drugs are covered under a separate tier.
Network Deductible
Co-Insurance
Network Out-of-Pocket Maximum (OOP)
Prescription Drug Tiers and Monthly Co-Pays
21 COMMUNITY ACTION FOR IMPROVEMENT, INC. 2022 BENEFITS GUIDE
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