4. Change in Medical PPO Network
A PPO network is a listing of doctors, hospitals, and other
facilities contracted to provide health care at a discount.
Administrative Changes
Private Health Care Systems Aetna Signature Administrators
6. Provider Search Is Easy with ASA
To see if your doctor is in the network, complete all fields, then
select “More Options.”
Administrative Changes
If you just want to see a
list of providers in your
area, click “Start Search.”
7. Provider Search Is Easy with ASA
To see if your doctor is in the network, search by name.
Administrative Changes
You can also search by
specialty, language, gend
er, and hospital
affiliation!
8. Provider Search Is Easy with ASA
To see if your doctor is in the network, search by name.
Administrative Changes
If your search was too
broad or narrow, you can
adjust the distance in the
search box on the left.
9. Doctor Not in the Network?
Double check before you give up!
Administrative Changes
Call CoreSource at:
Doctors use a variety of
addresses and names 800-848-3012
when contracting with
networks.
10. Use Caution When Asking Your Doctor
ASA PPO is different than other Aetna networks.
Administrative Changes
11. Doctor Not in the Network?
PDRMA Health Program can give you a nomination form, or
your provider can request to join online.
Administrative Changes
It takes approximately 90
days to add a provider to
the network.
12. Doctor Not in the Network?
If you are in the middle of treatment for an acute condition or
are pregnant, you can apply for Transition of Care benefits.
Administrative Changes
If approved, the plan will
pay your claims at the in-
network level for up to
90 days.
13. New PPO ID Cards – Vision Benefit Letter
Check your mailbox in late December for PPO ID cards and a
separate Vision Benefit Letter.
Administrative Changes
Note: No vision benefit
information on the 2012
medical PPO ID card.
Call PDRMA at 630-435-8998 to request a temporary PPO ID
Card letter or replacement Vision Benefit Letter.
14. New Forms for Open Enrollment, Nov. 7 – Dec. 2
PDRMA Health has updated many forms for participants to use
during Open Enrollment and in the future.
Administrative Changes
• Eligibility Form.
• Annual Certification Form.
• Beneficiary Change Form
• Coordination of Benefits Form.
• HIPAA Authorization Form.
15. New Forms for Open Enrollment, Nov. 7 – Dec. 2
PDRMA Health has updated many forms for participants to
use during Open Enrollment and in the future.
Administrative Changes
• Eligibility Form.
• Annual Certification Form.
• Beneficiary Change Form.
• Coordination of Benefits Form.
• HIPAA Authorization Form.
16. New Forms for Open Enrollment, Nov. 7 – Dec. 2
PDRMA Health has updated many forms for participants to
use during Open Enrollment and in the future.
Administrative Changes
• Eligibility Form.
• Annual Certification Form.
• Beneficiary Change Form.
• Coordination of Benefits Form.
• HIPAA Authorization Form.
18. Military Veteran Dependent Children
Eligible starting Jan. 1, 2012.
Eligibility Changes
• Ages 26 -30
• Unmarried
• Reside with employee
• Financially dependent on employee
19. Civil Union Spouses
Eligible effective June 1, 2011.
Eligibility Changes
• Requires county-issued Civil Union
Certificate.
• Couples can be same or opposite sex.
• Children of Civil Union Spouses.
21. Appropriate Level of Care
PDRMA’s plan design is meant to encourage participants to
seek the most appropriate level of care.
• Removing barriers to lower levels of
Benefit Changes
care
• Aligning cost share with cost of
service.
• Having procedures that prevent
unnecessary care.
22. Skilled Nursing Facility (SNF)
The requirement for a three-day inpatient hospital stay to be
eligible for coverage in a SNF no longer applies for 2012.
• SNF stay will only require:
Benefit Changes
• Medical Necessity
• Treatment Plan
• Discharge Date
• This change makes it possible for participants
to have care in a SNF after an outpatient
surgery or short hospital stay.
23. Emergency Room (ER) Copay
$100 ER copay. No deductible and coinsurance.
• If you are admitted to the hospital from the
ER, you do not pay the copay.
Benefit Changes
• This change makes it easier to know how
much a visit to the ER will cost in comparison
to Urgent Care or a Physician Office Visit.
• ER = $100
• Urgent Care = $30
• Specialist = $30
• Primary Care = $20
24. Pre-certification List Update
Pre-certification is beneficial to you and the plan.
• Health care delivery has changed and the pre-
certification list should reflect current standards.
Benefit Changes
• New list is shorter and providers will be more likely
to know what needs pre-certification.
• The changes to the list make it easier to get
procedures that are almost always medically
necessary.
• Precertification is not a guarantee the plan will
cover procedure – check your Plan Document.
25. Pre-certification List Update
Continue to pre-certify the following items.
Benefit Changes
• Inpatient Hospitalization and complex care.
• Speech/Occupational/Physical Therapy –
over 18 visits
• Durable Medical Equipment - over $1000
Pre-Certification: 866-939-4659
26. Pre-certification List Update
A shorter list of outpatient procedures to pre-certify.
• Back and neck procedures.
• Cranial banding.
Benefit Changes
• External counterpulsation.
• Hyperbaric therapy.
• Uvulopalatopharyngoplasty (UPPP).
• Unlisted laparoscopic procedure of abdomen.
• Facet joint injection.
• TMJ procedures.
• Hysterectomy.
Pre-Certification: 866-939-4659
27. Pre-certification List Update
Take note of two new items that require pre-certification.
Growth Hormone.
Increlex.
Mecasermin.
Benefit Changes
Pegasys/PEG-Intron.
• Sleep Studies Rebetron.
Roferon.
A Intron.
A Infergen.
• Injectable Medications Xolair.
Darbepoetin Alpha.
Epoetin Alpha, Epogen.
Procrit and Micer Blood Clotting
Factor IVIG.
Synagasis.
Medical Pre-Certification: 866-939-4659
CVS Specialty Pharmacy: 800-237-2767
28. Pre-certification List Update
You should get pre-determinations for items that no
longer require pre-certification in 2012.
No pre-certification required:
Benefit Changes
• Prosthetic and orthotic appliances
and devices over $500.
• Outpatient intravenous drug
infusion therapy - check the
injectable drug list.
CoreSource Pre-Determination:
888-848-3012
29. Next Steps
Look for… Go to the ASA PPO website and check
the network status of your preferred
New PPO ID Card providers. www.aetna.com/asa.
and Vision Letter in
late December.
Return the following to your Benefits
New 2012 Plan Coordinator:
Document early • Eligibility Form with any Open
next year. Enrollment changes, Nov 7 – Dec 2.
• Annual Certification Form.
• Coordination of Benefits Form (if you
have covered dependents).
• HIPAA Authorization (if desired).
30. Questions
Call 630-435-8998 for the PDRMA Health Program Team
Editor's Notes
Welcome to the PDRMA Health Program presentation of 2012 Plan Changes, an overview for participants.
In this presentation we cover three kinds of changes that will occur in 2012. Administrative changesEligibility Changes And Benefit ChangesWe understand change can be overwhelming, so please remember that the PDRMA Health Program Team is here to help you every step of the way.For a summary of the changes discussed in this presentation, you can reference the “Summary of Plan Changes for 2012” document available from your Benefits Coordinator.
There are three administrative changes in 2012 you should be aware of: The medical PPO plan will use a new provider network.PPO ID cards will look different, and you will obtain them in a new way.Also, many forms have been updated to better meet the needs of our member agencies and participants.
Starting January 1, 2012, the PDRMA Health Program is pleased to announce that the medical PPO plan will use a network called Aetna Signature Administrators, otherwise known as “ASA PPO.” A PPO network is a listing of doctors, hospitals, and other facilities contracted to provide health care at a discount.For the past 10 years, we have partnered with PHCS for our medical PPO network. However, changing to the ASA PPO network will give the PPO plan access to greater discounts than the PHCS PPO today, without causing a significant disruption in provider-participant relationships. ASA PPO’s greater discounts may also mean lower costs for you when you pay a deductible or coinsurance for services.Please note! A change in network does not mean a change in benefit coverage. The PDRMA Health Program will still cover the same benefits (except for specific changes noted later in this presentation), with many services covered at 90% in-network and 70% out-of-network. Physician office visits will still require just a copay. A change in network simply means a different list of providers to choose from to get in-network benefits.
While the thought of a new provider network might concern you, relax! The good news is almost all providers that you use today are in the ASA network. Most participants will not need to change doctors to receive in-network benefits. This is because the ASA network is larger than PHCS in the number of providers they have. Also, like PHCS, ASA is a national network and will provide in-network options outside Illinois for participants and dependents living out of state. One notable difference between the PHCS and ASA networks is the laboratories they contract with. Wehope you agree that choosing a different laboratory for blood work is not too difficult a change to make. For example, ASA PPO contracts with Quest Diagnostic laboratories.On that note, let’s get right to how you can find out if your preferred providers are in the ASA network, and what you can do if they are not! The first step is to go online and to the ASA network webpage at www.aetna.com/asa. On the opening screen, click the button at the bottom to “Enter DocFind.”
After you click DocFind, you will see this screen.Answer all the questions marked with a red asterisk (*).Click “More Options” so you can enter the name of your provider.
After you select “More Options” additional fields will appear.In the Name box, choose “Enter Provider’s Name” from the drop-down box.Type your provider’s last and first name.Select “Start Search.” To search for a group of doctors or Independent Physician Association (IPA), choose “Enter Group/IPA Name” from the drop-down box.In this example we are looking for a chiropractor named Dr. Jason Smith. Let’s see if he is in the network…
Yes, he is! If this Dr. Jason Smith was not the one you were looking for, you could adjust your search criteria to make sure you didn’t accidentally exclude the one you were looking for. A good tip when searching for providers is to use a wide search radius.
If you can’t find your preferred doctor on the first try, don’t give up. Try once again, and make sure you spell his name correctly and have a wideenoughdistance radius. If that doesn’t work, try doing an area search for his specialty using the office zip code or city. See if his name shows up in the list, possibly spelled differently, or as part of a medical group.If all your searches turn up empty, try calling CoreSource. CoreSource is equipped to answer all your questions about the ASA PPO network and help you determine the network status of your preferred providers. You can call CoreSource at their main customer service line at 800-848-3012. This number is also on the back of your current PPO medical ID card.
You should always be cautious when asking your doctor if she is in yournetwork before you receive and can show your insurance card. Like many health services companies, Aetna has a few different networks. Be very clear that you are asking about the Aetna Signature Administrators network. And we highly recommend following up with any confirmation from your doctor with a search for her on the ASA website!
If you can’t find your preferred provider on the website, and CoreSource confirms over the phone your provider is not currently in the network, you can ask your provider to fill out a form online to request to join the ASA network. Providers can go to Aetna’s main website www.aetna.com and look under the section for healthcare professionals for the request-to-join form. If you want to start the process, you can get a nomination form from the PDRMA Health Program or your Benefits Coordinator. Once completed, you will mail the form to Aetna. Once Aetna receives the nomination form, Aetna will contactyour preferred provider and begin the process of talking to him about joining the network. This process usually takes about 90 days, but can take longer depending on the provider. Providers must agree to discount their fees to be in the network, so sometimes the negotiation process can take time. And in some cases, providers might not want to agree to terms required to join the network. But it is worth a try if you really want to stay with your out-of-network doctor.
If your treating physician is not in the ASA PPO network and you are in the middle of treatment for an acute condition or are pregnant, you can apply for Transition of Care benefits through the PDRMA Health Program.We recognize that for certain acute medical conditions it is better to allow participants to stay with a doctor to complete their course of treatment. In approved situations, PDRMA will allow participants to see out-of-network doctors and will pay the claims as if they were in network. Conditions that might be eligible include second- or third-trimester pregnancies, recent major surgeries still in the follow-up period, and newly diagnosed or relapsed cancer. If you have a condition you think warrants continuing to see the same doctorfor a short period of time afterJanuary 1, please request a Transition of Care form from your benefits coordinator or the PDRMA Health Program Team. After you submit a request for transition of care benefits, someone from PDRMA Health will respond to you with a decision in writing.Remember, transition of care is meant to transition you to the new network. If you have ongoing medical needs, we recommend you look for an in-network provider to see after the approved transition period ends, in order to receive the highest level of benefits possible.
CoreSource will print and mail the new PPO ID Cards for use in 2012. You should receive your cards during the week of December 19th. Look for a large 9x6 white envelope from CoreSource’s Tinley Park address. Once you receive your 2012 ID card, be proactive about showing it to medical providers starting January 1, 2012. You will receive up to two ID cards for a family. If you need additional cards or should you need replacement cards, call CoreSource at the number on the back of your ID card to request extras. We know there are urgent situations where you might need an ID card quickly. If that happens, call the PDRMA Health Program Team to request a temporary ID Card letter. You can use this letter until your replacement card arrives in the mail.Another change regarding ID cards, is that vision plan information will not appear on the medical PPO card. Since the vision plan is an indemnity reimbursement plan, an ID card is not necessary; but you do need to know how to file a claim for reimbursement. Therefore, in 2012, everyone enrolled in the vision plan will receive a letter that outlines their vision benefit and provides all the information necessary to file a claim for reimbursement for vision expenses. This letter will be sent in December by the PDRMA Health Program.
We updated the following forms for the 2012 Open Enrollment season to make them more user friendly and to allow Benefits Coordinators to fax forms for faster processing.Eligibility FormAnnual Certification FormCoordination of Benefits Form Beneficiary Change FormHIPAA Authorization FormLet’s first talk about the Eligibility Form. The Eligibility Form is what you use to make changes to your benefits or contact information. During the year, when you experience a special event like having a baby, use this form to request a change. You must make mid-year change requests within 31 days of the special event.You also use this form to make any changes to your benefits during Open Enrollment, which will be from November 7 through December 2. Benefit changes requested during open enrollment become effective January 1, 2012. If you want to keep the benefits you have and keep the same people enrolled next year as this year, you do not need to complete a new Eligibility Form during open enrollment. Your benefits will carry over exactly as they are, unless your agency makes changes to the benefits it offers to employees. Your Benefits Coordinator will tell you if your agency is making any changes for 2012.Turn in all Eligibility Forms with Open Enrollment changes to your Benefits Coordinator by Friday, December 2. We cannot process any requests for changes received after the end of business on Friday, December 2.
Now let’s talk about the next three forms.Every year PDRMA Health requires all benefits-eligible employees to complete an Annual Certification Form. This form used to be called an “eligibility certification,” but it was changed to eliminate confusion between this form and the Eligibility Form that is used for changes. When you get the Annual Certification Form, review the accuracy of your contact information, benefits, and covered dependents (if applicable). If you need to update your address or phone number, you can do so on the form. If you want to change your benefits, ask your Benefits Coordinator for an Eligibility Form. Return the Annual Certification Form to your Benefits Coordinator by December 2.If you want to change your beneficiary, ask your Benefits Coordinator for a Beneficiary Change Form. DO NOT CHANGE BENEFITS OR BENEFICIARIES ON THE ANNUAL CERTIFICATION FORM. Until now you could change your beneficiary on the Annual Certification Form or on an Eligibility Form. Now the Beneficiary Change Form is separate. This change was made to allow Eligibility and Annual Certification Forms to be faxed, since PDRMA requires an original form with signature for beneficiary designations. All employees with dependents must complete a Coordination of Benefits Form each year. PDRMA Health provides this information to all claim processors, like CoreSource and Delta Dental. If you do not fill out this form, claims for your family members may be denied in 2012. Even if your family members do not have other coverage, please fill out this form and indicate there is no other coverage. Return this form with your Annual Certification to your Benefits Coordinator by December 2.
Finally, let’s talk about the HIPAA Form.PDRMA has always had HIPAA Authorization Forms available for employees to authorize the PDRMA Health Team to talk to someone else on their behalf about issues relating to “protected health information” known as PHI. PHI relates to your personal medical information, like medical conditions and when your claims are paid. This year, every employee will receive a copy of this HIPAA authorization form. Please consider filling it out, because without it, PDRMA is limited in the amount of information it can share with your spouse, other family member, or Benefits Coordinator if they call on your behalf in the future. If you prefer to always speak with PDRMA Health directly about claim issues or other topics involving your personal medical information, that is ok, too. You don’t‘ have to fill out the form.If you do want to authorize someone to receive your PHI, return the HIPAA Authorization Form directly to PDRMA at the address on the form or give to your Benefits Coordinator.
There are two eligibility changes for 2012 you should be aware of: The PPO, HMO, Dental, and Vision plans will cover military-veteran dependent children up to age 30.And we will update the PDRMA Health Plan Document regarding civil unions, based on a law passed this year.
Starting January 1, 2012, military-veteran dependents, at least 26 years of age and under 30, who are unmarried, reside with the employee, and are financially dependent upon the employee are eligible for the PPO, HMO, vision, and dental plans. A military veteran is someone who served as a member of the active or reserve components of any of the branches of the Armed Forces of the United States; and has received a release or discharge, other than a dishonorable discharge. This coverage until age 30 does not apply to active military dependents, just discharged veterans.If you havea military-veteran child who meets the outlined criteria you can enroll him for coverage effective January 1, 2012 during the Annual Open Enrollment period. Youshould provide documentation of age, residence, and financial dependence with the Eligibility Form. Yourmost recent year’s tax return is proof of financial dependence.
Civil union spouses and children of civil union spouses have been eligible for all PDRMA plans since June 1, 2011, based on a law signed in January 2011.Couples can be same or opposite sex.If you have a civil union spouse through the state of Illinois (or an equivalent union from another state) and want to change your benefit elections to enroll a civil union spouse, complete a PDRMA Health Program Eligibility Form and submit a copy of your civil union certificate to your Benefits Coordinator either within 31 days of the union or during the Annual Open Enrollment period.Children of civil union spouses are also eligible for the plan. Similar to marriage, you must provide a birth certificate or adoption certificate in addition to the civil union certificate to prove your relationship with your child.
There are three benefit changes to the medical PPO for 2012 you should be aware of: A change in requirements for coverage at a Skilled Nursing Facility for the PPO plan.A new copay for an Emergency Room visit for the PPO plan.And an updated list of procedures participants must have their provider pre-certify for the PPO plan.No benefit changes were made to the PDRMA HMO, Pharmacy, Dental PPO, or Vision plans for 2012.
The PDRMA Health Program regularly reviews its plan design in light of a very important concept – getting participants to the most appropriate level of care for their medical situation.What does that mean? It means…- Removing barriers to lower more appropriate levels of care.- Aligning cost share with cost of service.- Having procedures in place that prevent unnecessary care.This year all the benefit changes are meant to encourage you to use your benefits wisely. The changes are not meant to deter you from seeking care you need, but help you choose the right kind of care in the most efficient place.Now let’s get to those changes!
Currently under PDRMA’s medical PPO Plan, a you would need to meet three requirements to qualify for admission to a Skilled Nursing Facility. One of these long-standing requirements is a three-day, inpatient hospital stay. With today’s generally shorter hospital stays and the increase in outpatient surgeries, youmay need SNF care without spending three days – or even one day – in the hospital. To ensure you can receive the appropriate level of care and do not incur unnecessary costs in the event you need SNF care, the three-day, inpatient hospital-stay requirement to qualify was removed.In order to be eligible for coverage for SNF care, your doctor only needs to provide proof of medical necessity and complete a treatment plan that includes a diagnosis, the proposed course of treatment, and the projected date of discharge from the facility.
With the goal of encouraging you to choose the most appropriate level of care for injuries and illnesses – doctor’s office, urgent care, or ER – the ER benefit was changed from deductible-and-coinsurance coverage to copay coverage with a $100 copay for ER visits so you can quickly and easily evaluate your choices and the associated cost-impact in selecting the appropriate level of care.This means you will just pay the $100 copay for ER visits, not a deductible or coinsurance.In line with industry standards, if you are admitted to the hospital from the ER, you do not pay the copay.Like other copays in the PPO Plan, ER copays do not go toward your deductible or out-of-pocket maximum.
Our current PPO plan has always required pre-certification of certain procedures. Pre-certification is beneficial to the PDRMA Health Program PPO plan because it protects the plan from covering procedures that are not medically necessary. It also benefits you by protecting you from obtaining a procedure that isn’t medically necessary and having the claim denied.Over time, health care delivery standards are modified and the pre-certification list should follow suit. The 2012 PDRMA Health PPO pre-certification list is very in line with current industry standards, which focus on pre-certifying procedures that are more likely not to be medically necessary. The 2012 list is actually shorter, with far fewer outpatient procedures needing pre-certification. Your provider should be very accustomed to pre-certifying the items on the 2012 list.Even though the pre-certification list has been scaled back, the plan will still only cover benefits as defined in the Plan Document. Remember, the purpose of pre-certification is to make sure a procedure or item is medically necessary. Check your plan document or contact CoreSource customer service to determine if something is a covered benefit as well as being medically necessary.
Please continue to have your provider pre-certify the following items, as they are still on the list, though some have fewer restrictions.1. Inpatient Hospitalization and complex care like Skilled Nursing Facility stays, care for Transplants, Bariatric surgery, as well as Home Health or Hospice Care.2. Speech, occupational, and physical therapies, but only after 18 visits.3. Durable Medical Equipment, but only if it will cost over $1,000.Again, remember, the purpose of pre-certification is to make sure a procedure or item is medically necessary. Check your plan document or contact CoreSource customer service if you have questions about what benefits are covered. For example, not all kinds of speech therapy is covered, even if it is medically necessary.
The current 2011 PDRMA Health Plan requires all procedures obtained in an outpatient surgical facility be pre-certified. However,For 2012, there is a short defined list of procedures that must be pre-certified.You may notice that colonoscopy is no longer a procedure that requires pre-certification!Don’t worry about memorizing this list, as it will be available on the PDRMA Health Program website.
One completely new item on the pre-certification list is sleep studies. If your provider suggests that you undergo a sleep study to diagnose a sleeping disorder, please make sure your provider calls to pre-certify it.Another somewhat new item is injectable medications. In most cases you should get your injectables through the pharmacy plan. When you get an injectable through the pharmacy, CVS Caremark initiates a prior authorization process with your physician akin to pre-certification. To order an injectable medication through the Specialty Pharmacy call 800-237-2767.But in 2012, if you happen to get your injectable medication through your physician directly, please be sure he calls to pre-certify your injectable by calling 866-939-4659. The list of injectables that will require pre-certification in 2012 are listed on the right hand side of the screen. As you can see these are specialty injectables, like growth hormones and blood clotting drugs. You do not need to get items such as allergy shots or vaccinations pre-certified.
Here are a few items no longer on the pre-certification list -- prosthetic and orthotic appliances and devices over $500, and outpatient intravenous drug infusion therapy. However, please make sure to get pre-certification for injectable drugs obtained in the physician’s office. For a list of injectable drugs that require pre-certification go to the PDRMA Health Program website.But please note that participants still need to be discerning about the procedures they choose even if they no longer require pre-certification. For example, orthotics will no longer require pre-certification, but this does not guarantee the PPO plan will cover all orthotics. Without pre-certification the participant can now decide to get the orthotics without taking that step, but it is possible the plan will deny his claim if the orthotics are found not to be medically necessary. For these and other items that no longer require pre-certification, PDRMA Health strongly encourages you to ask your provider to request a pre-determination of benefits from CoreSource. Pre-determination is a process by which your provider can find out how and if the plan covers a procedure or appliance, which can prevent you from unknowingly purchasing a service or appliance that the plan may not cover. Call CoreSource at 888-848-3012 for pre-determination. This phone number is also on your ID card.
And that concludes our presentation of changes for 2012. But, before we finish, let’s go over a few next steps for you.First, don’t forget to go to the ASA PPO website and check the network status of your preferred providers at www.aetna.com/asa. Remember that the PDRMA Health Team is here to help you if your provider doesn’t seem to be in the network.Second, make sure you turn in all the necessary forms to your Benefits Coordinator by Dec 2, including:An Eligibility Form with any Open Enrollment changes.Your Annual Certification Form.A Coordination of Benefits Form if you have dependents.And the HIPAA Authorization Form if you ever want PDRMA Health to be able to share your protected health information with someone else.In late December you should receive a New PPO ID Card and Vision Benefit Letter. If you don’t have a new card or letter by January 1, call the PDRMA Health Program Team. Once you get your ID card, start showing it to all your providers. Keep your Vision Benefit Letter in a safe place. If you newly enroll in the HMO for 2012 you will receive a new ID card in late December as well. Current HMO participants may receive a new ID card as part of the continual upgrade from magnetic strip to bar code, however if you are a current HMO participant and don’t get a new ID card, don’t worry. Your current card is fine.Early next year your Benefits Coordinator will give you a new plan document. And finally, don’t forget, you can refer to the Summary of Plan Changes for 2012 available from your Benefits Coordinator for a summary of key points from this presentation. Thank you for taking the time to listen to this presentation about PDRMA Health’s 2012 Plan Changes.
