Summary Plan Description

Aetna Choice POS II Network

Effective June 1, 2015, the plan contracted with Aetna to provide a PPO network. The Board of Trustees selected the Aetna Choice POS II network because it is a nationwide network that includes a wide variety of providers from all provider specialties.

Network (PPO) Services

When you use a network provider, the cost of services and supplies is discounted. The following guidelines apply:

  • You are strongly encouraged to use network physicians, urgent care centers, hospitals, and other providers. If you use a network provider, most covered medical expenses are paid at 90 percent by the plan and at 10 percent by the patient. When the patient's coinsurance reaches the $2,300 or $4,600 annual coinsurance maximums, benefits that would otherwise be paid at 90 percent are paid at 100 percent for the remainder of that calendar year.
  • You are not required to designate a primary care doctor. However, for the best quality of care, the plan encourages you and your dependents to establish an ongoing relationship with a primary care doctor.
  • You are not required to have a referral from your primary care doctor if you need to see a specialist.
  • If you use a network provider, that provider is required by contract to get approval from Aetna before providing certain services. This safeguards you from incurring medical expenses that may not be covered by the plan.
  • Network providers will file your claims and accepts direct payment from the plan. Your network provider can collect the $10 office visit copayment at the time of your appointment.

Medicare-eligible retirees expenses are processed at the network level.

Non-Network (Non-PPO) Services

Although you may receive care from any licensed provider covered by this plan, using a non-network provider may result in higher out-of-pocket expenses for you and your dependents. Several examples are provided below:

  • If you use a non-network provider, most covered medical expenses are paid at 80 percent of the maximum allowable fee by the plan and at 20 percent of the maximum allowable fee by the patient. These services always require 20 percent coinsurance and these coinsurance payments do not apply toward the $2,300 or $4,600 annual coinsurance maximums.
  • The office visit copayment is $20 instead of $10.
  • The patient has a $200 copayment for inpatient facility admissions.
  • The provider may charge more for a procedure or service than the plan allows. You are responsible for the amount that exceeds the plan's maximum allowable fee.
  • The provider may require that you pay for his or her services up front.
  • The provider may not obtain the required approval for a service that requires precertification. There are penalties for failing to obtain approval on certain services. Please see Medical Review Programs for more information.
  • You may have to file a paper claim if the provider is not willing to file the claim for you.