Your Health Benefits
Open Choice® (Passive) PPO HRA Plan
The Open Choice® (Passive) PPO plan with Health Reimbursement Account (HRA) preferred provider organization (PPO) medical coverage with a special fund used to meet covered health care expenses (including the deductible) during the year. When the fund is depleted, you meet any deductible amount remaining, and then the medical plan pays a percentage of your covered expenses. If you don't use all of the money in the fund by the end of the year, any unused amounts can be rolled over to the following year, as long as you stay in the plan.
This plan is available to Crawford employees who do not live within Aetna's network area. If you enroll in this plan, you have the option of traveling to a network provider and taking advantage of discounted rates for medical services.
How the Plan Works
Crawford makes a deposit to your fund.
At the start of each plan year, Crawford deposits a fixed amount of money into the fund. For the plan year starting January 1, 2012 and ending December 31, 2012, the contribution will be $750 for individual, $1,125 for employee plus one, and $1,500 if you enroll for family coverage.
The fund is reduced by the full cost of the care you receive.
As you have covered medical and prescription drug expenses during the year, withdrawals are made automatically from your fund to meet them. At the same time, these withdrawals are applied against your deductible. If your fund runs out of money and you haven't yet met the deductible, you'll need to meet the rest of the deductible out of your own pocket.
On the other hand, if you have money left in your fund at the end of the year, it is rolled over and added to the deposit Crawford makes for the following year. By spending carefully and making informed health care decisions, you can build savings for future health care expenses – as long as you stay in the plan.
After you meet the deductible, the medical plan starts to pay benefits.
After the fund is depleted and you've met the deductible, the PPO medical plan starts to pay benefits. The plan pays a percentage of the expense and you pay the rest. The part you pay is called coinsurance. Under the plan, you may receive care from any licensed provider. If you decide to travel to an area where Aetna maintains a provider network, you can take advantage of special lower rates. This means your benefits may be based on a lower amount if the doctor or other care provider is charging a discounted rate for your particular service. This can result in a lower out-of-pocket cost to you.
To find network providers, use DocFind®, Aetna's online provider directory. When you are asked to "select a plan," click on Aetna Standard Plans, then select Open Choice® PPO. You can search the online directory for a specific doctor, type of doctor or all the doctors in a given zip code and/or travel distance.
|Use network providers. Remember, you pay less when you use network providers — doctors, hospitals and pharmacies that are in the plan. When you and your family use these providers, you save money because network providers have agreed to accept negotiated rates for their services and you pay a lower portion of coinsurance stretching your fund dollars.|
The Summary of Benefits (PDF) chart shows the plan's benefits for the plan's major covered expenses. Keep in mind that the plan's benefit (for example, 80% after the deductible) is the same no matter who provides your care. However, if a network doctor charges less for a service than a non-network doctor, your benefit is based on a lower amount and your 20% share will be lower.
Coverage for Pre-existing Conditions
The plan has a "pre-existing condition" rule that limits coverage for expenses incurred for a condition you had before the plan's effective date. A "pre-existing condition" is a condition for which you:
- Received treatment or services; or
- Took prescribed drugs or medicines;
. . . during the 90 days right before your coverage under this plan went into effect.
The rule is: For the first 365 days after this plan takes effect, expenses for treatment of a pre-existing condition are not covered. There may be an exception to this rule in the case of a child whom you adopt or for whose health coverage you are responsible because of a child support order. Also, under certain circumstances, the 365-day exclusion period may be reduced by your "prior creditable coverage," if applicable. For details about the pre-existing condition rule and any exceptions or modifications to it, refer to your Summary Plan Description (coming soon). The "pre-existing condition" rule does not apply to your dependents under age 19.
Your Prescription Drug Benefits
Aetna Rx Home Delivery, a pharmacy that fits your life.
If you or a covered family member uses prescription medication daily or regularly, you can take advantage of the savings and convenience offered by Aetna Rx Home Delivery, Aetna's mail-service pharmacy. You can order up to a 90-day supply of medication and have it delivered directly to your home. Best of all, your cost for a 90-day supply will be the same as it would be for a two-month supply at a retail pharmacy. It's like getting one month free.
The service is easy to use. Once you place your initial order with your doctor's original prescription (either mailed or faxed to Aetna Rx Home Delivery), you can order refills by mail, phone or on the web at www.aetnarxhomedelivery.com, and you can pay with your credit card. Read the details about Aetna Rx Home Delivery (PDF).
Open Choice Passive PPO HRA Q&A
Is a PCP required under the Open Choice Passive PPO HRA plan?
No. You are not required to select a PCP when you enroll in the plan, nor is a referral needed from a PCP when you visit a specialist.
Isn't this plan better for the young and healthy?
Aetna researched the impact of health care consumerism over time, including taking a close look at the health status of Aetna HealthFund members. This study showed that employees of all ages and health conditions have enrolled in an Aetna HealthFund HRA plan. In fact, the average age of the population enrolled in the Aetna HealthFund HRA is in line with the average age enrolled in the other products.
Are prescription drug expenses paid from the fund?
Yes. It's important to remember that the full amount of an expense is paid from the fund, in other words, what you would pay in the absence of benefits. This means the full price of your prescription is deducted from your fund.
If my child lives away from home in an Aetna network area, can he or she take advantage of the discounted rates for network providers?
Yes. If your child is covered under the plan and lives within an Aetna network area, he or she may receive care from network providers. If a discounted rate applies to the service he or she receives, the plan's benefit will be based on the lower fee.
While meeting my deductible, will network discounts apply?
Yes. Network discounts apply if you use a network provider, hospital, pharmacy or Aetna Rx Home Delivery.
When am I responsible for filing a claim?
If you visit a provider not in Aetna's network, you are responsible for submitting this claim to Aetna which will reduce your fund balance. If there is no money available in the fund, the eligible expense will be applied toward your plan deductible. Claims for services by non-network providers or hospitals must be mailed to Aetna using the medical claim form (PDF).
Are prescription drugs limited to a preferred list (formulary)?
No. You may purchase generic or brand name drugs. Some medications may require prior authorization from Aetna or may be subject to quantity limitations. Use of generics will limit your out-of-pocket expenses and stretch your fund dollars.
What if I visit a provider not in Aetna's network?
You are responsible for submitting this claim to Aetna which will reduce your fund. If there is no money available in the fund, it will be applied toward your plan deductible which you are responsible for. Claims for services by non-network providers or hospitals must be mailed to Aetna using the medical claim form (PDF).
Does the Plan's higher deductible discourage members from receiving the care that they need?
No, Aetna HealthFund members are actually seeking increased preventive care because these services are completely paid by the Plan. This plan provides members with an incentive to take a simple questionnaire, called a Health Risk Assessment to identify potential health risks and highlight lifestyle modifications that could improve their overall health. The plan also includes disease management programs for members with chronic medical conditions such as diabetes or heart disease.