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Comprehensive (PPO) Medical Plan FAQs

  1. What is the difference between Aetna Choice POS II and Aetna?
  2. How do I find a doctor in the Aetna Choice POS II network?
  3. Do I need a referral to see a specialist?
  4. Do I have to see a doctor in the Aetna Choice POS II network?
  5. What should I do if I am hospitalized for an emergency?
  6. Do I need authorization from the insurance company before receiving certain services?
  7. What do I do if my doctor makes me pay up-front?
  8. If I have surgery and my 10% co-pay exceeds $5000, do I have to pay that much?
  9. How do I know if my doctor is an Aetna Choice POS II provider?
  10. If my in-network physician refers me to a lab for tests, will my lab work be covered at the in-network level?
  11. When will I receive my medical card and will it be in my name?
  12. How do I order extra/replacement insurance cards?
  13. Do I use the ID number on the benefits card or my Social Security number?
  14. How can I find out what services are covered?
  15. Do I have to make a co-payment?
  16. Do I have a deductible?
  17. Is there a separate deductible for office visits, hospital visits, chiropractic visits, etc?
  18. Do I have to pay my $750 deductible all at once on my first visit for the year?
  19. I have a family of 5 on my insurance; do we need to each meet the $750 deductible?
  20. Does the deductible carry over each year?
  21. Who can I add to my medical plan?
  22. When can I dd/drop a dependent from my insurance?

 

1. What is the difference between Aetna Choice POS II and Aetna?

Aetna Choice POS II is the Preferred Provider Organization (PPO) network. Aetna is the claims administrator responsible for processing claims and pre-authorizing certain services for both the Comprehensive (PPO) and High Dedcutible PPO plans. You can find an Aetna Choice POS II provider by visiting www.aetna.com/docfind.

2. How do I find a doctor in the Aetna Choice POS II network?

For detail instructions on how to find a doctor in the Aetna Choice POS II network, please click here.

3. Do I need a referral to see a specialist?

No. With the Comprehensive PPO and High Deductible PPO plans, you can choose any doctor in any specialty. As long as they are in the Aetna Choice POS II network, you will receive the in-network level of benefits.

4. Do I have to see a doctor in the Aetna Choice POS II network?

No, you may see any doctor outside of the Aetna Choice POS II network but the benefit is reduced for the Comprehensive and High Deductible PPO plans if you go out of network. The in-network deductible is $750 and thereafter services will be covered at the 80% level. The out-of-network benefit starts with a $1,500 deductible and thereafter services will be covered at the 60% level. If you have family coverage (defined as 3 people or more), the in-network deductible is $2,250 and the out-of-network deductible is $4,500.

5. What should I do if I am hospitalized for an emergency?

In the case of an emergency, you must notify Aetna at the 877-number on the front and back of your benefit card, within 48 hours. After you are discharged from the hospital, you may want to make sure the physician you will see for your follow-up care is in the Aetna Choice POS II network in order to receive the higher benefit coverage.

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6. Do I need authorization from the insurance company before receiving certain services?

Yes, in a non-emergency situation it is best to make sure all in-patient or out-patient services are covered BEFORE having the service. Please contact Aetna Member Services at (877) 204-9186 if you have any questions. (The 877-number is listed on the back of your benefit card.)

7. What do I do if my doctor makes me pay up-front?

If your doctor makes you pay your co-insurance up-front, retain the receipt and when you receive the Explanation of Benefits (EOB) from Aetna, make sure your payment does not exceed the amount actually owed. If what you paid up-front is more than you owe, your doctor’s office should refund the difference or give you a credit toward a future visit.

8. If I have surgery and my 10% co-pay exceeds $5000, do I have to pay that much?

No, the in-network out of pocket maximum for the Comprehensive plan is $2,000 per year and the out-of-network out of pocket maximum is $4,000. In either case you will not pay more than the out of pocket maximum for that year.

9. How do I know if my doctor is a Aetna Choice POS II provider?

The network can change at any time so before your office visits, it is best to ask your physician is still a participating member of the Aetna Choice POS II network. You can also check the website www.aetna.com/docfind.

10. If my in-network physician refers me to a lab for tests, will my lab work be covered at the in-network level?

Possibly. It is always best to confirm whether a service provider is in-network or not by calling Aetna at (877) 204-9186 or by visiting their website at www.aetna.com/docfind. Some examples of service providers are labs, x-ray facilities, urgent care centers, hospitals, and behvioral health facilities.

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11. When will I receive my medical card and will it be in my name?

The sooner we receive your Benefit Enrollment Form or Change Form, the sooner your card will be produced and mailed to your home. Aetna produces our benefit cards so it is vital that you keep your address up to date in our system. This will ensure that you receive your card as quickly as possible. The name printed on the benefit card will always be the subscriber. Your spouse or domestic partner and children will not receive a card in his/her name.

12. How do I order extra/replacement insurance cards?

You may order cards through the Aetna Navigator website or via phone at (877) 204-9186.
To order a card online, go to www.aetna.com. You will need to register as a new member. Once you have registered, click on Get an ID Card on the left hand side of the screen.

13. Do I use the ID number on the benefits card or my Social Security number?

Your benefits card contains a ten-digit ID number unique to you, which can be used when seeing your doctor. Claims can be submitted using your ten-digit ID number or your Social Security number.

14. How can I find out what services are covered?

You can contact Aetna directly to find out if a certain service or procedure is covered at (877) 204-9186. You may also contact Benefits Administration at (858) 784-8487 or benefits@scripps.edu for information on what services are covered.

15. Do I have to make a co-payment?

No, the comprehensive and High Deductible medical plans do not have a co-pay. For example, you do not have to pay $30 before your chiropractic visit or any other office visit.

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16. Do I have a deductible?

If you receive care from an in-network provider, you have a $750 deductible per person and a $2,250 deductible for family coverage (defined as 3 people or more) for the Comprehensive plan. If you see an out-of-network provider, a $1,500 deductible per person and a $4,500 deductible for family coverage (defined as 3 people or more) will apply. For the High Deductible plan, there is a $2,000 deductible for employee and a $6,000 deductible for employee plus dependent coverage.

17. Is there a separate deductible for office visits, hospital visits, chiropractic visits, etc?

No. If you go in-network there is one deductible per person per year regardless of the medical service(s) provided.

18. Do I have to pay my $750 deductible all at once on my first visit for the year?

No. If your first in-network visit of the year is $100, then you will only pay the $100 and have $650 left of your deductible to meet under the Comprehensive plan. However, you do not want to pay anything until you have received your Explanation of Benefits (EOB) from Aetna and compare it to the doctor's bill to make sure you are being billed the correct amount. Your EOB will also tell you how much you have left to meet on your deductible and on your out-of-pocket maximum for the year.

19. I have a family of 5 on my insurance; do we need to each meet the $750 deductible?

No. For example, on the Comprehensive plan the in-network family deductible is $2,250, which means that only 3 people per family need to meet their $750 deductible. After 3 people have met their deductible, services will be covered at 80% for the entire family. The out-of-network family deductible is $4,500.

20. Does the deductible carry over each year?

Yes. If you meet your deductible during the last three months of a calendar year, your deductible will carry over to the next calendar year and you will not have to meet it again.

21. Who can I add to my medical plan?

Employees eligible for any medical plan can add their spouse or domestic partner and child(ren). To add a domestic partner, CA employees must be California Registered Domestic Partners and FL employees must sign an affidavit. Grandparents, parents and siblings are not eligible to be covered on the plan.

22. When can I add/drop a dependent from my insurance?

You may add or drop a dependent within 31 days of your date of hire or the date you become benefit eligible; within 31 days of a qualified status change such as a birth of a child, marriage, divorce, dependent gaining or losing other coverage, etc.; or during Open Enrollment.

To add or drop a dependent from your medical and/or dental insurance due to a qualified status change, you need to complete and submit a Benefits Coverage Change Form along with proof of dependency and/or proof of status change. The form needs to be turned into Benefits Administration within 31 days of a status change. If the form is received after 31 days, you will have to wait until Open Enrollment to make your change.

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