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CategoryQuestionAnswer
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AcupunctureIs acupuncture covered?Yes.
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Add OnsWhere is Silver Sneakers available in Ithaca?Finger Lakes Fitness Center, East Shore Gym, Tompkins Cortland Community College Fitness Center, and Seneca Fitness to name a few. You can also nominate your gym to participate.
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Add OnsIs a gym membership at Island Health and Fitness covered?Island Health and Fitness is not currently participating with Silver Sneakers, but you can nominate this gym to participate.
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AdministrativeIf we have a new treatment that we didn't have before, how will we know if Aetna will cover it and if BCBS would have covered it?Aetna customer service can provide information on new treatments prior to members having a service. Network providers also know what services are covered and can submit for pre-authorization prior to the service. If a denial were received, Members can contact the ENV Call Center for next steps.
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AdministrativeWhy aren’t we comparing this plan to BCBS, and rather to Hartford?Hartford is the plan that all post 65 retirees are currently on.
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AdministrativeWhat are the premiums? What if I already paid for the entire year with Hartford?Many retirees have zero premium plans, which of course will not change. Premiums for other plans have not been set, and retirees will recieve individualized communications regarding the plans they retired under. For those retirees who pre-paid premiums to The Hartford, ICSD will work with you to either roll over the premuims to Aetna or refund unused premiums from The Hartford.
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AdministrativeWill rates be impacted due to coronavirus expenditures?The rates are currently locked in and will be for one full year.
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AdministrativeAre spouses covered if the ICSD member dies?Surviving spousal benefits are pursuant to collective bargaining agreements and not the health insurance plan itself. Please consult the collective bargaining agreement you retired under, or contact ICSD Human Resources Department for further review.
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AdministrativeAre we getting a choice to keep Hartford?No, all current retirees on the Hartford plan would roll over to the Aetna MAPD plan if this was selected.
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AdministrativeIs the district cost shifting? What kinds of dollars are we talking about for the ICSD budget?This transition would save about $1 million over two plan years.
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AdministrativeWill ICSD still cover IRMAA?Yes, if the district is currently covering your IRMAA costs, they will continue to do so.
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AdministrativeWill we be transitioning again to another program in a year?The district is obligated to investigate any and all cost-saving opportunities as it relates to benefits for employees and retirees. There are no plans to move again, however, if another products makes itself available in the next few years that provides as good or better benefits and can save costs, the district will review this as an opportunity.
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AdministrativeWill we still pay for Medicare from Social Security and then be billed for Aetna or would those payments be rolled together?Yes, you will still pay for Medicare Part B as you currently do. Aetna would be paid for through the District billing.
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AdministrativeWas billed annual premium based on Hartford or Aetna?The annual premium that was already billed was based on the Hartford plan.
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AdministrativeCan we make this information easier to access on ICSD website?Yes, the district will be making this information easier to access on the website.
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AdministrativeThere has been a delay in ENV responses, will this improve?Typically, if there is ever a delay in response from ENV, this is due to the fact that we are working on your issue to get a complete and correct response from the carriers. If you are ever concerned, please feel free to reach out and check in.
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AdministrativeIf I do not want to be a part of an Advantage Plan will I lose my retirement benefit?If Ithaca CSD transitions to a Medicare Advantage Plan, that would be the only option for medical benefits in retirement over age 65.
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AdministrativeHow much is the District saving? How much are retirees saving? How is savings being passed on to retirees? Our insurance premiums went up this year. If we switch to Aetna, and it costs less, do we get a refund? Will our premium go up again next year?The district will be saving approximately $1 million over two fiscal years if this transition occurs. The Hartford will be ICSD's retiree insurer through December 2020, and their premiums will be unchanged through that time. Premiums under Aetna should see some benefit, it is unknown to what extent at this time. Premiums, historically, do increase every year as the cost of health insurance typically outpaces the inflation rate.
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AdministrativeI really think that it’s very important to let our retirees know that looking for a plan that will give us the same or better coverage at a lower cost is an ongoing, yearly process.  A shift to Aetna this year doesn’t mean that we’ll still be with Aetna next year.This is correct, ENV and the district will always be reviewing cost-saving opportunities for the district provided that benefits can be the same or better. While it is not desireable to continually change, we will bring legitimate options to the administration.
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AdministrativeWill domestic partners be covered?Domestic partner benefits are pursuant to collective bargaining agreements and not the health insurance plan itself. Please consult the collective bargaining agreement you retired under, or contact ICSD Human Resources Department for further review. Quick rule of thumb, if your domestic partner was covered with The Hartford, nothing will change by moving to Aetna (as coverage is not contingent on the insurer, but the collective bargaining agreement you retired under).
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AdministrativeHow are spouses covered? As in Hartford?Spousal benefits are pursuant to collective bargaining agreements and not the health insurance plan itself. Please consult the collective bargaining agreement you retired under, or contact ICSD Human Resources Department for further review.
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AmbulanceAre all ambulance services covered including air ambulance?Yes.
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ChiropracticWe were told over and over again that with Hartford, a service/doctor would be covered only if Medicare covered it first so why is this language for chiropractic care under Hartford included here? And does that mean with Aetna, a non-Medicare chiropractic visit is totally covered? With no annual max?  And does it follow that other non-Medicare providers would also be covered, i.e. physical therapists?(i.e. any situations when chiropractic wouldn't be covered)?Medicare does not cover maintenance chiropractic care, so The Hartford included some extra services such as $15 copay for maintenance with a $1000 annual max for such non-Medicare covered services. Aetna covers all chiropractic coverage at a $0 copay. The Aetna plan will cover non-Medicare chiropractic maintenance at $0 copay. Physical therapy is covered when medically necessary for $0 with the Aetna plan.
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ChiropracticIs physical therapy covered as well as chiropractic?Yes.
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Compassionate CareWhat is compassionate care?Please see flyer.
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DentalIs there any dental coverage?No, however, the district is working on a dental solution for retirees.
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DentalAre dental implants covered?Generaly, Original Medicare (Parts A and B) as well as Medicare Advantage plans do not include coverage for services like preventive, and major dental or dentures. There are some exceptions, such as when a hospital stay is involved, i.e. reconstruction under certain circumstances, i.e. injury to the mouth/jaw.
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DermatologyIs Dermatology covered?Dermatology is covered if the services are considered medically necessary.
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General QuestionsIs there a sample plan document?Yes, the plan document is call the Evidence of Coverage (EOC). The EOC is created and distributed to each member once the plan benefits are accepted by the plan sponsor and enrollment has begun. TA sample, generic EOC is available by reaching out to ENV.
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General QuestionsWhat happens if the federal government decides to defund Medicare Advantage plans?There is full bi-partisan support of the Medicare Advantage program by the Federal Government. There is consistently increasing focus on expanding and improving MAPD plans for Medicare retirees. MAPD now out paces Medicare Supplemental plans in membership across the country. Members on Medicare Advantage retain all of their Medicare rights and privileges. Should a retiree elect to revert back to original Medicare or should the Federal Medicare Part C Program (Medicare Advantage) change or be 'defunded', members will still have their original Medicare benefits.
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General QuestionsHow difficult is it to get through to Aetna on the phone?Aetna exceeds service level guarantees for customer service and phone inquiries. They have multiple service centers nationally to provide coverage through all time zones and to provide back up if any one center gets busy. The Center for Medicare and Medicaid Services (CMS) Star Rating for both Health and Drug Customer service is a full 5 out of 5 stars.
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General QuestionsI have heard that Medicare Advantage plans are cheaper because they reimburse providers at a very low rate. How might this affect patient care?Providers who are contracted in Aetna's network are paid the reimbursement they agreed to in their contract. Non-contracted providers are paid by Aetna at the same level as they are paid through original Medicare & Medicare Supplemental plans. Aetna can provide lower rates because our high CMS Stars quality ratings afford higher reimbursements by the Federal Government. Costs are also controlled through efficiencies of simplified administration, better member health outcomes, and scalability of 1.4M Medicare members nationally.
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General QuestionsCan we ask that the EOBs use less papers?Yes, Aetna members only receive one EOB in the mail per month summarizing all medical and pharmacy services for the month. Members can also elect not to receive paper EOBs in the mail and only receive them online.
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General QuestionsWill there be a separate benefit administrator like Benistar?Aetna administers all medical-pharmacy benefits and in first class, Medicare member specific customer service center. ENV will also service as your advocate.
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General QuestionsPlease give examples of when prior authorization would be needed.Cochlear implants, Chiari Malformation Surgery, Electric/motorized wheelchairs or scooters, hip surgery to repair impingement syndrome, hyperbaric oxygen therapy, lower limb prothestics, spinal procedures, reconstructive procedures that may be considered cosmetic, shoulder arthroplasty, private duty nursing, inpatient confinements, certain implants, endoscopic nasal balloon surgery are the main items that require PA.
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General QuestionsWill we no longer provide our Medicare card as primary? Only show the Aetna card?Correct, you can file your Medicare card away if the transition occurs and only use your Aetna card.
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General QuestionsExplain the difference between supplemental plan and advantage plan.Medicare Supplement is a plan that supplements coverage after Original Medicare Parts A and B. The Medicare Advantage replaces the administration of Original Medicare Parts A and B and offers prescription coverage.
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General QuestionsWhy is different language used for equal benefits? 100% after Medicare vs. $0 copay.The Medicare Supplement policies pay after Medicare pays the standard 80%. The supplement policy picks up the remaining % so therefore it is listed that way. Because Aetna will replace the administration of Medicare, they provide a copay from the start. That copay, in most categories, is $0.
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General QuestionsIs this an HMO or a PPO?PPO
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General QuestionsWhat is happening to my benefits? They told me they would be the same or better, but this isn't telling me that. What does this all mean?The Aetna plan has been customized to meet or exceed current benefits. It is important to note that Ithaca's group plan is custom and cannot be compared to other Aetna plans that are in the community and cannot be compared to individual Medicare Plans.
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General QuestionsWhat is the deductible amount for single members?None
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General QuestionsWould you also confirm if the id card will NOT contain the word “social security number” anywhere on the card?There will not be any mention of a "social security number" on the ID card.
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General QuestionsWhen a member does need reimbursement how many days does it take Aetna to pay a member from when you receive the member information?  How long it will take them to receive payment? Once Aetna receives the reimbursement request, the standard turnaround time is 30 days for processing and this does not include mailing time for the check. With that being said, as long as all necessary information is received, reimbursement claims typically only take 7-10 to be completed.
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General QuestionsDid Hartford have a chance to bid on the insurance to see if they could meet or better Aetna’s price?Yes, but unfortunately the prices were still much higher. The Hartford does not get the same subsidies from the Federal Government as the MAPD product does with Aetna because Hartford only can receive subisdy on the Rx. Aetna can receive subsidy for medical and Rx.
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General QuestionsCan you explain the role/relationship between ENV and ICSD and why it is so important for people to call ENV if there are issues?ENV is the consultant for ICSD and although retirees are welcome to call the insurance carrier, ENV acts as an advocate for you and can work with the carriers to get answers to your questions and to get issues resolved.
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General QuestionsWhat do online tools offer to the user?Please see flyer.
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General QuestionsSince Aetna must pay services formerly paid by Medicare, doesn’t a lower medical premium rate depend on actual experience?Not necessarily as there are many factors that impact the premium rates provided by Aetna.
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General QuestionsWhat is the difference between a non-Medicare covered service and a non-Medicare participating provider? Is there a difference?A non-Medicare covered service is a service not included in original Medicare benefits. Medicare Advantage plans can providea dditional coverage for services that original Medicare does not. A non-Medicare participating provider may be referring to a provider who does not accept standard Medicare alowable reimbursements. This is also sometimes referred to as a provider who "doesn't take Medicare". The provider is still participating with Medicare and eligible to receive Medicare payment, but may charge a 'limiting charge' of up to 15% above Medicare allowable billing amounts. Under Aetna's MA C04 ES PPO proposed for Ithaca CSD, the member would still pay $0 (the plan cost share). Aetna would pay the claim, AND any balance bill/limiting charge on the member's behalf.
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General QuestionsWhat is the best way to contact ENV for questions?Email: callcenter@insurewithenv.com or Phone: 315-641-5848, 800-887-9146
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General QuestionsSince BCBS was an indemnity plan and the Hartford was a PPO plan, weren't they different by definition?Indemnity plans pay in and out of network benefits the same. The Aetna plan is a PPO but is designed for members to have the same benefits both in and out of network.
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Genetic TestingIs genetic testing for cancer covered on the plan?Yes, when specific medical criteria is met.
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HearingIs there coverage for hearing aids?Yes, a $1,000 allowance every 36 months.
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Home CareA retiree was told that the district would not cover in-home infusion therapy, an item that would have been covered by BCBS. Consequently, this individual had to go to an infusion center with a compromised immune system during the current COVID-19 pandemic.Aetna Medicare advantage does cover home health care (HHC) for home infusion/injectable therapy. Precertification prior to beginning the HHC services is ONLY required if a member resides in FL. In all other states, precertification is not required for HHC.
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Home CarePlease provide a definition for home care.Home care includes but is not limited to part-time or intermittent skilled nursing and home health aide services, physical therapy, occupational therapy, speech therapy, medical and social services, medical equipment and supplies. Prior to receiving services, your doctor must certify that you require these services at home. You must be homebound, meaning that leaving home is a major effort.
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HospiceHospice Care- Hartford covers any costs beyond Medicare.  Under Aetna what happens if there are costs that Medicare doesn’t cover?  What happens if the Hospice isn’t Medicare certified?Original Medicare will cover Medicare participating Hospices. Aetna's network team does not know of any opt-out Hospice's in upstate NY. There is no difference between "certified" and "participating"; a Hospice is either Medicare participating or opt-out. Aetna will pay the 15% limiting charge on any provider who does not accept Medicare.
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InpatientInpatient services- Hartford pays $100 after Medicare, plus coverage for 365 days after Medicare ends. Aetna says $0 copay.  Nothing is said about what gets covered after Medicare ends.  Does this mean that Aetna will cover MORE than 365 days after Medicare ends?After 365 days, the new year starts. It will always be $0 and there would never be a time a member had to pay out of pocket for this.
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InpatientIs inpatient covered for observation?Yes.
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International CoverageInternational Coverage- This chart makes it look like we had no international emergency care under Hartford. The chart we were given in February showed under Hartford: “Emergencies covered at 100% up to lifetime benefit maximum of $250,000 within the first 60 days of travel"Correct. The current Powerpoint states these same limits you referenced with Hartford. Aetna has no deductible, lifetime limit, or time frame. Aetna has no annual max.This means a member would pay the claim and be reimbursed in full for emergencies.
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International CoverageInternational Coverage: How would it work under Aetna?  Would we still pay upfront while abroad and then get reimbursed when we submit the bills when we return? Would we submit them to the district to send to Aetna or do we have to deal with Aetna? A member would submit to Aetna a translated bill for reimbursement. If a member can’t get a translated bill, Aetna can assist, but the process may take slightly longer. If a member pays, they will receive reimbursement.
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International CoverageDoes the international coverage cover being airlifted from a cruise ship?Air ambulance is covered when medicall necessary. Benefits are provided for urgent and emergency care anywhere in the world.
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International CoverageHow does Aetna's international coverage compare to the GeoBlue plan we had with the Hartford?The GeoBlue plan was a supplemental international coverage plan that had a limit on the medical coverage. This plan and plans like it are no longer able to be sold in the state of NY. Under the Aetna program, there is no daily or dollar amount limit on the international emergency benefit.
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International CoverageWhat is the definition of emergency and urgent care as it relates to international coverage?A "medical emergency" is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse. If you have a medical emergency: Get help as quickly as possible. Call for help or go to the nearest emergency room or hospital. Call for an ambulance if you need it. You do not need to get approval or referral first from your PCP. As soon as possible, make sure that your plan has been told about your emergency. Aetna needs to follow up on the emergency care. You or someone else should call to tell Aetna about your emergency care, within 48 hours if possible. Please call the Customer Service number on the member ID card.
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MassageIs massage covered?If there is a medically necessary reason for massage and the service is rendered by a licensed provider, the CPT code can be submitted for research.
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Mental HealthWill mental health visits to a therpaist on a regular schedule be covered if you have a diagnosis?Yes.
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NetworkIf a provider is not in-network and does not submit to Aetna, what is the process for a member?Often, once a non-participating provider understand the passive PPO nature of the Aetna MAPD, then they are happy to bill. Non-participating providers are paid by Aetna at the same level as they are paid through original Medicare & Medicare Supplemental plans. As the 2nd largest Group MAPD carrier in the nation, most offices are already familiar with billing to Aetna. Should Ithaca CSD decide to go with Aetna, Aetna will offer to do a provider outreach to educate any remaining non-participating providers in the area this fall. Many populations in the area already use Aetna MAPD plans such as Cornell University, Spencer Van Etten and Horseheads Schools.
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NetworkWhat if there is a denial of service? What is the appeal process?The denial and appeal process meets and exceeds all CMS requirements for Medicare Advantage plans. If Aetna continues to deny the claim, please see ENV's appeal process.
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NetworkIf this is not a Medicare supplement plan, do we still need Medicare and will Aetna cover non-Medicare providers?You do still need to sign up for Medicare. Providers don't have to accept Medicare rates to be paid out of network by this plan. Aetna will pay medicare rates plus an additional fee for the member. Just like the Hartford plan, if a provider opts out of Medicare, they will not take your Aetna plan. This is very rare.
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NetworkIf moot, why is there a separation between in-network and out-of-network?Typically in the marketplace, there is a difference between member cost-share with in-and out-of-network. This is not the case for the Ithaca plan.
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NetworkIf a claim is not covered by either Medicare or Aetna, to whom do we appeal at the district? Please give specific contact name, email and phone number.
The ENV Call Center will be happy to assist in any claims issue and can be reached at 1-(800)-887-9146 or email callcenter@insurewithenv.com
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NetworkCan you share the list of in-network doctors?The Aetna plan is a Passive PPO. Aetna can call a provider and explain to them how to bill "out-of-network". In Ithaca's case, the plan is the same in- and out-of-network. This plan is different than other Medicare Advantage plans where a member would truly have to be in-network to receive coverage. This plan provides a passive network, which means that as long as the doctor can bill and is willing to accept new patients, members shouldn't have an issue.
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NetworkIf a member wants to see a surgeon in Manhattan but doesn’t take Medicare; what can the member do to try to get this covered? What if my Doctor, whom I have had for the last 17 years does not accept a Medicare Advantage Plan?When a provider “doesn’t take Medicare” it usually means they don’t accept Medicare allowable reimbursement. The provider is normally still eligible to receive Medicare payment, but may charge a ‘limiting charge’ of up to 15% above Medicare allowable billing amounts.  Under our MA ESA PPO proposed for Ithaca CSD, the member would pay $0 (which is their plan cost share for both OP surgery and IP surgery), and Aetna would pay the claim, AND any balance bill/limiting charge on the member’s behalf.
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NetworkBut what if the provider is truly a Medicare Opt-out provider? If the provider is truly a Medicare Opt-Out Provider, the patient would know that in advance since the provider, by law, must have the patient sign (before any services are agreed upon) an Affidavit Contract acknowledging that the provider doesn’t accept insurance or Medicare, and the member would be directly responsible for all charges. Providers must submit written confirmation annually to CMS/Medicare if they want to continue that status. These providers can charge patients whatever they want since there is no relationship with Medicare/CMS (Centers for Medicaid and Medicare Services) to protect the patients. Original Medicare nor Medicare Advantage plans are able to cover the charges. The Hartford does not cover opt out providers either.
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NetworkIn the notes under the slide there is a mention of a “provider directory.” Did Hartford have a similar directory? I’m asking because if all Medicare providers are considered in-network for Aetna as described in Slide 2, why is a provider directory even necessary?Provider directory is really more for plans that aren’t a passive PPO or a limited Aetna plan. Ithaca members will be able to go to any provider, as long as they are not an opt out, whether they are in-network with Aetna or not.
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PrescriptionAre retirees required to get specialty drugs through CVS mail order?No, members are not required to obtain their specialty medications from CVS Specialty pharmacy. They can obtain them from any in-network pharmacy that has their medication available.
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PrescriptionIs the 90 day supply limit for all specialty drugs?There is no days' supply limit on specialty medications, so there is nothing prohibiting a member from getting a 90 days' supply as long as the drug is covered and there are no quantity limits put in place by CMS. Not all drugs qualify for mail order and some retail pharmacies will provide a 90 days' supply.
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PrescriptionWill my prescriptions stay the same?Yes, your prescription copays will stay the same as what you pay currently. Specific drugs change tiers on a regular basis and annually so members will need to review the formulary.
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PrescriptionWill I be able to use Kinney Drugs for my prescriptions?Yes.
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PrescriptionI pay $4 for a 90 day generic with Express Scripts, will CVS charge the same?Your prescription copays will not change and you will pay up to, but no more than your copay. See formulary to see which tier your Rx falls in.
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PrescriptionWill our prescriptions automatically be rolled over or will we have to start from scratch giving the new company our prescriptions?If you have mail order medications, you will need to get new scripts for those medications and have them run through Aetna. If your Rx will need prior authorization, your doctor will have to send those notes into Aetna. For retail pharmacy Rx, show your new ID card to obtain Rx.
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PrescriptionAre lidocaine patches covered? Patches are on the formulary, require PA just as they did with Hartford.
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PrescriptionDrug formulary is different - the fact that moving to a different formulary would mean some people would have to switch from current medications to ones covered by Aetna is not clearly explained in this presentation.Members do not have to switch current medications. Some prescriptions may fall to a higher copay and some may fall to a lower copay. Members do have the option to talk to the doctor about alternatives if a Rx falls to a higher copay. In some cases it is the exact same medication, just a different dosage or way to administer.
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PrescriptionPrior authorizations would be needed? Doctor's responsibility?Because CMS has oversight, they do put in prior authorization on certain drugs that could pose a risk to retirees (just like Hartford). PAs are done behind the scenes by the doctor.
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PrescriptionWhat is the formulary and how does that affect me?The formulary is a list of drugs and what tier they fall on for the Aetna plan. You will want to review the formulary to see where your drugs fall.
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PrescriptionDo I have to do mail order?It is not required that you do mail order for your prescriptions.
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PrescriptionCVS pharmacy discounts- does this mean that my prescriptions will cost more if I buy them elsewhere?Every pharmacy charges a different amount for prescriptions. However, members will always pay up to their copay regardless of the pharmacy that is used.
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PrescriptionWhat does "extensive pharmacy network" mean? 67,000k pharmacies nationwide
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PrescriptionIs Wegmans in-network?Yes.
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PrescriptionCan we check the formulary?The formulary will be posted on the ICSD website and you may contact the ENV Call Center to be emailed an electronic copy.
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PrescriptionIs there a list of "OTC" medications?While most OTC drugs are not covered, Aetna has a CVS discount program that offers members up to 20% off on OTC drugs at the store or online. Any "OTC-like" drug that the plan pays for is listed on the formulary.
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Preventive ServicesWhen does the calendar for mammograms reset… is it each January or 12 month period?One screening mammogram every 12 months for women age 40 and older. Calendar resets every 12 months. Pap smear screening is only available once every 24 months with Hartford. Aetna allows one pap smear every 12 months.
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Preventive ServicesA retiree was told by ENV the district would not cover additional mammograms for a breast cancer survivor, an item previously covered by BCBS if prescribed by a physician. For this service to be covered, it would have to be medically necessary with the applicable information provided by the physician. Medicare WILL cover more than one mammogram if medically necessary as determined by doctor.
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Preventive ServicesFor Routine Physical Examinations, I am again stunned that any non-Medicare covered services are included under Hartford. And why does $0 copay equal more coverage here (as opposed to equal coverage under Physician Office Services above); does it imply that non-Medicare services here are covered with no maximum? Medicare covers a very basic wellness visit that typically is much less than an annual physical that a physician would provide. Hartford had an additional provision to cover up to $1000 per year of non-Medicare covered services (in this case, additional services provided as a part of an annual physical). Aetna covers a full annual physical at $0 with no annual maximum. Because there is no maximum it is a better benefit than Hartford.
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Preventive ServicesAre flu / shingles shots covered under the plan at the doctor’s office or do they need to submit a reimbursement? If the member receives the vaccine at the doctors office, the vaccine won’t be denied? Today with Hartford if they receive Shingrix at the doctor, they have to submit the denial for reimbursement. Flu shots are covered under the Medical plan Part B drugs, and Shingles is covered under RX Part D drug benefit. The $0 cost office visit would be covered under the medical plan. When any part D vaccine is billed by a doctor’s office, they generally cannot submit a pharmacy claim electronically, their EOB will show that procedure denied and request the office send a manual claim to part D. Instead of doing this, usually they will just bill the member.

Claims are not automatically paid under the part D plan if a doctor submits them as a medical claim, but Aetna will decline the claim with instructions that is should be submitted to the part D plan. The reason this cannot be done automatically is because pharmacy claims require the prescription NDC and medical claims do not contain this information. The doctor’s office CAN manually submit the information to Aetna for payment but it is very rare that they do this, they will generally just send a bill to the patient. When this happens, Aetna's customer service team will reach out to the doctors office, obtain the necessary information and request that the pharmacy claim be processed internally.

With that being said, if the vaccine is denied as covered under part D, Medicare customer service has a workflow to send these to pharmacy requesting the claim be paid at the applicable copay. When the request is made, the rep will specify whether Aetna should pay the doctor or the member. If the member has already paid the doctor, it is quicker for us to reimburse them directly. If they haven’t paid, we can send the payment to the doctor.
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Social WorkIs counseling covered through a social worker? Certified Social Workers are ineligible under Medicare, but Licensed Master Level Social Workers are eligible for the Aetna Medicare Advantage product.
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VisionDoes the vision coverage include the refraction fee?Yes
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VisionIs a diagnostic eye exam including a refraction covered? The medical refraction would be limited to one per year? We have a member that requires a refraction every 6 months due to likelihood of Glaucoma and family history. Would only one be covered?Yes, Routine Eye Exams include a refraction and are covered one every 12 months. When a member has a medical reason for additional services, the provider submits the documentation and the benefit is considered for the additional coverage. If deemed medically necessary, it will be covered.
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VisionEyewear: Medicare covers only eye glasses after cataract surgery.  Am I understanding correctly that the Aetna plan also covers eyewear for non-cataract people?  What specifically does conventional eyewear cover?  What types of things does the $100 additional reimbursement every 24 months cover?Yes, the reimbursement is for eyewear even without cataracts. If a member needs to upgrade frames/lenses, need contacts, etc. It has to be eyewear from a qualified optometrist or ophthalmologist.
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