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Payments
Payments for the Retiree Medical Plan - POS II A and B options
You and the Plan share costs for covered treatment and services. You pay a fixed copayment for covered items such as a POS II network doctor's office visit and emergency room visits. For other types of care, you must satisfy an annual deductible and if applicable, an inpatient hospital deductible before the Plan starts paying. If you meet your annual out-of-pocket limit, the Plan pays 100% of most covered costs for the rest of that calendar year.
Coinsurance
You share in the cost of most covered expenses. For some services, such as hospital stays, the coinsurance will be a percentage of the cost of the covered service once the deductible has been satisfied. For other services, such as office visits to a POS II network provider, the copayment will be a fixed amount. For outpatient prescription drugs, there is a percentage copayment.
- Fixed copayment — A set amount you pay for covered services or treatments such as POS II doctor's office visits, certain related lab work and x-rays and hospital emergency room visits.
- Percentage coinsurance — This is your share of the cost of certain covered services or treatments, such as retail and home delivery prescriptions. For medical expenses other than outpatient prescription drugs, once you meet your deductible, you and the Plan share covered costs until you reach your out-of-pocket limit. Your share is your percentage coinsurance and is typically 20% or 40% for the POS II B and 25% or 45% for the POS II A depending on the providers you select and whether you live in a network or an out-of-network area. If you reach your annual out-of-pocket limit, the Plan pays 100% of most covered charges for you for the remainder of that calendar year.
Deductible
The deductible is the amount of covered expenses you must pay each calendar year before the Plan begins sharing the cost. Fixed amount copayments do not apply toward this amount. Outpatient prescription drug percentage copayments are not subject to nor do they count toward the annual deductible.
An additional hospital deductible applies to inpatient hospital services. For network hospitals, it is $200, and for non-network hospitals, the deductible is $400 for the POS II B and $300 for network hospitals and $600 for non-network hospitals for the POS II A.
The network deductible for medical, mental health and substance abuse expenses is currently $300 per year for an individual or $600 per year for a family for the EMMP POS II B. The non-network deductible is currently $600 per year for an individual or $1,200 per family for the EMMP POS II B. For the EMMP POS II A, the network deductible is $500 per year for an individual or $1,000 per year for a family, and the non-network deductible is $700 per year for an individual or $1,400 per year for a family.
There are several ways for a family to meet the deductible, including:
- Two covered members of your family each meet the individual deductible.
- One person meets the individual deductible and other members of your family have combined covered charges equaling an individual deductible.
- No one person meets the family deductible, but the combined covered charges of all members of your family equal the family deductible.
Note: A family deductible cannot be met by only one person.
Charges that Do Not Count Toward the Deductible
- Charges above reasonable and customary levels.
- Charges not covered by the Plan.
- Charge of $500 for failure to precertify non-POS II network hospital stays.
- POS II copayments.
- Any outpatient prescription drug percentage copayments.
- Charges for a private hospital room above the cost of the hospital's most common rate for a semiprivate room.
The deductible is applied to your claims in the order Aetna processes them, not when the provider collects the money from you. This means if you pay your deductible to one provider, it may not be applied to your annual deductible if Aetna has received and processed other claims first. Please be sure to always get an itemized bill from your provider and retain proof of your payment.
Adjustments to billed charges
When providers submit charges for payment, the following factors affect the amount that will be considered eligible for reimbursement. References to these limitations may appear on your explanation of benefits (EOB). Contact Aetna Member Services for more information. A predetermination of benefits is strongly recommended before you incur any major or unusual expenses.
Reasonable and customary limits
Allowable amounts for services are determined by reasonable and customary (R&C) limits. Aetna’s network is based on a percentage of the Medicare allowable rate or on reasonable & customary limits for the geographical area as determined by Aetna.
R&C limits are based on data from several surrounding regions rather than one specific zip code. R&C limits apply only to non-network providers and services.
Example:
A non-network provider charges $80 for a particular medical procedure, the reasonable and customary limit is $30, and the network provider charge is $25. Only $30 of the $80 charge will be allowed for payment. At the 60% benefit level for the POS II B option, the Plan will pay $18 and you will be responsible for paying $12 plus the $50 difference between the reasonable and customary limit and the non-network charge for a total of $62. If you used a POS II provider, you would be charged only the network-negotiated rate of $25 at the 80% network reimbursement level for the POS II B option. You would have paid only $5 for the same service.
Incidental charges
Aetna's current standards for incidental charges are based on the Current Procedural Terminology (CPT) codes and guidelines authored and revised by the American Medical Association since 1966. CPT coding has become the most widely accepted format, by both government and private health insurance programs, in reporting physician procedures. CPT coding furnishes health care providers with a uniform system to accurately describe medical services. CPT coding guidelines explain that services commonly carried out as an integral component of a total service or procedure should not be reported as a separate procedure.
When a claim is submitted with multiple CPT codes, Aetna uses the CPT guidelines to determine whether the charges should be considered as separate costs or if the charges are typically considered as one cost. If Aetna determines that the charges should have been submitted together under one CPT code, the separate charges would be considered incidental to the primary procedure, and the amount allowed for reimbursement would be the amount for the primary procedure.
Example: Your provider administers an immunization and submits separate charges: one for the medication administered in the immunization and another for administering the shot. In most cases, an immunization should be submitted for payment using one CPT code. If it is submitted as two separate charges, Aetna uses the CPT guidelines and pays only one CPT code for the cost of the medication. The charge for administering the shot is considered to be incidental and is not paid.
Network providers have agreed to accept incidental charges reductions; however, you are responsible for incidental expenses when you use a non-participating provider or if you have signed a statement in the provider's office saying you will be responsible for incidental charges.
Multiple surgeries (including bilateral procedures)
When multiple surgeries are performed, a health industry standard calculation method is used to reflect the cost savings that accompany services rendered during the same operative session. The amount allowed for multiple procedures performed during the same operative session are as follows:
- 100% for the primary procedure (typically the most complex procedure),
- 50% for the second procedure, and
- 25% for all subsequent procedures.
Example: You have foot surgery involving three toes on the same foot. The following chart explains how the multiple surgery calculation works if you use a network provider and assumes you are enrolled in the POS II B option.
|
A |
B |
C |
D |
E |
|
Multiple Surgery Charges Submitted |
Multi-Surgery % |
Allowed Amount |
Plan pays at 80% |
You Pay |
|
$80.00 |
100% |
$80.00 |
$64.00 |
$16.00 |
|
$60.00 |
50% |
$30.00 |
$24.00 |
$6.00 |
|
$40.00 |
25% |
$10.00 |
$8.00 |
$2.00 |
|
$180.00 |
|
$120.00 |
$96.00 |
$24.00 |
Note: Network providers have agreed to accept multiple surgery reductions.
Example: You have foot surgery involving three toes on the same foot. The following chart explains how the multiple surgery calculation works if you use a non-network provider and assumes you are enrolled in the POS II 'B' option. Procedures performed by a non-network provider are first subject to R&C limits. Those allowed amounts are further reduced by multiple surgery calculations.
|
A |
B |
C |
D |
E |
|
Multiple Surgery Charges Submitted |
Multi-Surgery % |
Allowed Amount |
Plan pays at 60% |
You Pay |
|
$80.00 |
100% |
$80.00 |
$48.00 |
$32.00 |
|
$60.00 |
50% |
$30.00 |
$18.00 |
$42.00 |
|
$40.00 |
25% |
$10.00 |
$6.00 |
$34.00 |
|
$180.00 |
|
$120.00 |
$72.00 |
$108.00 |
Surgical assistants/assistant surgeons
If your physician uses a non-physician during a procedure, any charges submitted for the non-physician's services will not be allowed unless a non-physician meets the definition of physician. For the medical treatment or surgical procedures to be considered covered medical expenses, a physician must perform the procedure. See definition of physician under Key Terms.
If your physician is assisted during the procedure by another physician (assistant surgeon), billed charges will be reduced to 25% of the R&C allowance or 25% of the participating fee if in-network for each surgical procedure, according to the allowance for assistant surgeon fees.
Multiple imaging diagnostic tests
When certain multiple imaging diagnostic tests (e.g., MRIs, CT scans, ultrasound) are performed on the same date of service, the amount allowed for reimbursement is 100% of the fee schedule (network) or reasonable and customary charge (non-network) for the first diagnostic test and 50% for subsequent tests ordered during a single encounter.
No volitional control
Charges incurred if you had no volitional control in determining the provider will be reimbursed at 80% after the deductible for the POS II B and 75% after the deductible for the POS II A option, as though a network provider was used.
Non-network charges incurred through the use of a network facility for radiologists, anesthesiologists, pathologists, neonatologists, intensivists, and hospitalists will also be reimbursed at 80% after the deductible for the POS II B and 75% after the deductible for the POS II A option, as though a network provider was used. However, charges incurred for non-network radiologists, anesthesiologists, pathologists, neonatologists, intensivists, and hospitalists through non-network providers continue to be reimbursed as non-network.
Reimbursement to non-network providers will be limited to a reasonable and customary amount, rather than billed charges. In the event you are billed for any balance at a network facility or in an emergency situation at a non-network facility, by a non-network physician you may submit the balance to Aetna for additional processing. Only amounts that are above the reasonable and customary fee schedule will be considered for additional reimbursement. Charges for services not covered by the Plan will not be reprocessed.
Out-of-Pocket limits
The annual out-of-pocket limit helps protect participants from high medical costs by increasing the reimbursement level when your payments for covered charges reach certain dollar limits. This limit is separate from the limits established for outpatient prescription drugs. In POS II areas, the limit is different depending on whether you use network or non-network providers.
|
EMMP POS II A option - Annual Out-of-Pocket Limits |
|||
|
|
Fixed |
Percentage coinsurance*: |
Until you reach your annual out-of-pocket limit of: |
|
If you live in a Medical POS II area and: |
|||
|
Use network providers for medical services |
$40 (PCP) or $55 (Specialist) |
25% |
$4,500 per person |
|
Do not use network providers for medical services |
N/A |
45%** |
$18,000 per person |
|
If you do not live in a Medical POS II area and: |
|||
|
Use network providers for medical services |
$40 (PCP) or $55 (Specialist) |
25% |
$4,500 per person |
|
Do not use network providers for medical services |
N/A |
25%** |
$4,500 per person |
|
If for precertified*** mental health care, you: |
|||
|
Use mental health network providers |
$40 |
25% |
$4,500 per person |
|
Do not use network providers. Magellan's network, not Aetna's, is used for mental health and substance abuse care. |
N/A |
45%** *** |
$18,000 per person |
* After the annual deductible and, if applicable, the inpatient hospital deductible is met.
** All non-network out-of-pocket expenses are subject to reasonable and customary limits.
*** Call Magellan for precertification. See Precertification in the Mental Health and Substance Abuse Care section for details.
|
EMMP POS II B option - Annual Out-of-Pocket Limits |
|||
|
|
Fixed |
Percentage coinsurance*: |
Until you reach your annual out-of-pocket limit of: |
|
If you live in a Medical POS II area and: |
|||
|
Use network providers for medical services |
$25 (PCP) or $40 (Specialist) |
20% |
$3,000 per person |
|
Do not use network providers for medical services |
N/A |
40%** |
$15,000 per person |
|
If you do not live in a Medical POS II area and: |
|||
|
Use network providers for medical services |
$25 (PCP) or $35 (Specialist) |
20% |
$3,000 per person |
|
Do not use network providers for medical services |
N/A |
20%** |
$3,000 per person |
|
If for pre-certified*** mental health care, you: |
|||
|
Use mental health network providers |
$25 |
20% |
$3,000 per person |
|
Do not use network providers. Magellan's network, not Aetna's, is used for mental health and substance abuse care. |
N/A |
40%** *** |
$15,000 per person |
*After the annual deductible and, if applicable, the inpatient hospital deductible is met.
** All non-network out-of-pocket expenses are subject to R&C limits.
*** Call Magellan for precertification. See Precertification in the Mental Health and Substance Abuse Care section for details.
Using both network and non-network providers
If you live in a POS II network area and you choose some network and some non-network providers, the annual out-of-pocket limit works this way:
- Network and non-network out-of-pocket maximums must be met separately, unless you are eligible for Out of network area benefits.
- Once your annual out-of-pocket total from a network provider reaches $3,000 for an individual (or $6,000 for a family) for the POS II B and $4,500 for an individual (or $9,000 for a family) for the POS II A, the Plan pays 100% of covered expenses when you use network providers. However, at this point, the Plan would still pay only 60% of covered expenses for non-network medical providers for the POS II B and 55% of covered expenses for non-network medical providers for the POS II A.
- Once your out-of-pocket total from a non-network provider reaches $15,000 for an individual (or $30,000 for a family) for the POS II B and $8,000 for an individual (or $36,000 for a family) for the POS II A, the Plan pays 100% of covered medical expenses when you use a non-network provider.
Expenses that do not count toward the out-of-pocket limit for either POS II option
- Charges above reasonable and customary limits.
- Charges not covered by the Plan.
- Charge of $500 for non-compliance with medical preadmission review process.
- Charge of $500 for failure to precertify inpatient non-network and out-of-network mental health or substance abuse services.
- Copayments for outpatient prescription drugs.
- Charges for a private hospital room greater than the cost of the hospital's most common rate for a semiprivate room.
No lifetime maximum
There is no maximum lifetime limit on benefits paid by the Plan with the exceptions of the $25,000 lifetime maximum on bariatric surgery.