Health Care Benefits for SPFPA

Managed Choice POS

When Do You Receive In-Network Benefits

If you live in the Managed Choice POS service area, each time you or an enrolled dependent needs medical care, you decide whether to go through the Managed Choice POS network or go out-of-network. The maximum benefits under Managed Choice POS are available through the network.

To receive in-network benefits for covered expenses:

• You first go to the Primary Care Physician (PCP) you selected from the Managed Choice POS Provider Directory.
• The PCP will provide the treatment you need or will refer you to a specialist for Specialty Care.
• If hospitalization is needed, the PCP or specialist will arrange for Hospital Care.
  

Emergencies require faster response that might not allow you time to contact your PCP immediately. Therefore, Managed Choice POS has an Emergency Care process for in-network benefits.

Compared with out-of-network benefits, Managed Choice POS in-network benefits cover more services, such as:

• Well-baby care and immunizations
• Routine physical examinations
• Chiropractic care
• Birth control pills
• Private duty nursing

Managed Choice POS network coverage also pays higher benefits for alternate care such as:

• Skilled nursing facilities
• Home health care
  

Managed Choice POS does not cover certain medical services and supplies, and no benefits will be paid for those expenses.

If you choose to receive care that is not covered, you will be responsible for paying the full cost of the service or supply even if you receive the service from a network provider.

Benefits for psychiatric and substance abuse treatment are provided only through the
separate network managed by Value Options. To see the section on Psychiatric and Substance Abuse Treatment, click on the link at the top of this screen.

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How Do You Select Your Primary Care Physician

Managed Choice POS requires you to list a Primary Care Physician for yourself and each enrolled dependent. The Provider Directory lists Managed Choice POS Primary Care Physicians. If you wish, you and your dependents may have separate PCPs. The list includes:

• Family practitioners
• Internists
• Pediatricians
• General practitioners
  

In-network benefits have fewer administrative requirements. For example:

• You usually have no claims to file
• No advance approvals are required
• Female participants may select an obstetrician/gynecologist as a secondary PCP.

In selecting a physician, you may want to call the physician's office to determine:

• If the doctor is accepting new patients
• How long you must wait to schedule a routine appointment
• What is the process for scheduling an appointment for treatment of an illness or an injury

You can also call Blue Cross Blue Shield of Illinois Member Services if you want more information regarding a particular PCP. For example, you can receive information on the doctor's:

• Medical specialization, if any
• Medical school of graduation
• Date of graduation.

Because the PCP is the key to helping you manage your health care needs, you may change your PCP at any time to find the physician relationship that works best for you. Call Blue Cross Blue Shield of Illinois Member Services to change your PCP.

The reasons you select a certain physician or wish to change to a new physician are personal. You are not required to give a reason for making these changes, although Aetna may ask you for your reasons for information only.

The Managed Choice POS Provider Directory is updated periodically. If your PCP leaves the network, Member Services will ask you to name a new PCP. A physician may leave the network for many reasons. Network membership is voluntary for providers just as use of the network is voluntary for you.

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How Do You Use Your PCP

Your PCP manages all the medical care you receive from the Managed Choice POS network. That means, to be eligible for in-network benefits, all medical services and supplies must be provided or authorized by your PCP. To receive in-network benefits:

• Call your PCP and make an appointment.
• When you arrive for your appointment, present your Managed Choice POS ID card to the physician's business office.
• Your PCP will assess your medical needs and advise you on appropriate care.
• Your PCP will authorize any tests, hospitalization, or referrals to a specialist. You will receive in-network benefits for referrals made by the PCP. If you make your own arrangements for treatment, or insist on receiving care not recommended by your PCP, only out-of-network benefits will be available.
• You pay $10 for the office visit. For regular office visits related to pregnancy, only one copayment is required for the first visit. The remaining office visits for the pregnancy do not require a copayment. If you request it, you will receive a receipt for the copayment. If you have a Flexible Spending health care account, you can file the receipt for pretax reimbursement.
• The physician will receive payment for the rest of the cost of the visit from Aetna. The physician's office will take care of any required paperwork.
• If prescription drugs or other medically necessary supplies are required, your PCP will give you a written prescription or will authorize you to obtain the supplies. By using a network pharmacy, you pay a $7 copayment to the pharmacy for up to a 30-day supply of the prescription. If you have a Flexible Spending health care account, you can receive pretax reimbursement for the copayment. Out-of-network benefits will apply if you obtain the prescription drugs or supplies from an out-of-network pharmacy.
• Out-of-network benefits will apply if you obtain the prescription drugs or supplies
  from an out-of-network pharmacy. To see more information about out-of-network benefits, click on the link at the top of this screen.

Remember, in-network benefits apply only to covered services and supplies provided or authorized by your PCP.

As soon as your coverage becomes effective, you should make an appointment with your PCP to establish a relationship. The office visit is important for many reasons, including:

• To give your PCP an opportunity to collect information on your medical history
• To establish you as a patient of the physician
• To give you an opportunity to get to know your physician and to ask questions about any special process for contacting the physician after hours, during weekends or holidays, or anytime during an emergency.

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How Do You Receive Specialty Care

If your PCP determines that specialty care is necessary, the physician will refer you to a specialist. A specialist may include:

• Dermatologists
• Oncologists
• Allergists
• Cardiologists
• Plastic surgeons
• Urologists
• Surgeons
• Orthopedists
• Neurologists
• Podiatrists.

Your Managed Choice POS Provider Directory lists specialists included in the Managed Choice POS network. If the network does not include the type of specialty you need, your PCP will refer you to an out-of-network specialist. In this instance, as long as the specialty care is authorized by your PCP, the care will be eligible for in-network benefits.

This rule has three exceptions:

• You may schedule up to three visits within a plan year to a network chiropractor without authorization from your PCP. However, the chiropractor may not refer you to other specialists for network benefits. Additional visits within a plan year must be authorized by your PCP to be eligible for network benefits. Chiropractors are not covered out-of-network.
• Female participants may self-refer to a network obstetrician/gynecologist.
• Separate procedures are required for psychiatric or substance abuse treatment. These procedures are explained on page 28.

If your PCP suggests specialty care, you decide whether:

• To have your PCP authorize a referral to a specialist so you can receive in-network benefits for the specialty care or
• To make your own arrangements for a specialist and receive out-of-network benefits for the specialty care.

If you make your own arrangements, only out-of-network benefits will be available even if you choose a network specialist.

Depending on the treatment, specialty care obtained in the network may involve a $10 copayment. For example, an office visit to a specialist will have a copayment, but surgery performed by a specialist will not have a copayment.

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How Do You Receive Hospital Care

To receive in-network benefits for hospital care, the hospital admission must be authorized by your PCP or by the specialist to whom your PCP has referred you. All hospital services must be provided by a network hospital with two exceptions:

• If your physician determines that an out-of-network hospital is more appropriate for certain procedures or conditions, your benefits will be provided as though the hospital is a network hospital.
• In a life-threatening emergency, you should seek treatment at the nearest emergency facility and then follow the emergency care instructions described in the next section of this booklet.

Your Managed Choice POS Provider Directory lists the hospitals and other medical facilities in your Managed Choice POS network.

Expenses for hospital care that qualify for network benefits are paid in full. Present your Managed Choice POS ID card upon admission. The hospital should take care of all paperwork to receive reimbursement for the cost of the care you receive.

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How Do You Receive Emergency Care

Managed Choice POS in-network benefits cover you for emergency care wherever the emergency occurs. Here's how it works:

A medical emergency is defined as a sickness or injury where failure to obtain immediate medical care could be life-threatening or cause serious harm to bodily functions. In a medical emergency, severe symptoms develop abruptly and signal a need for immediate medical attention. Examples are:

• Apparent heart attack
• Severe or multiple injuries
• Obvious fractures
• Lacerations (deep, requiring sutures).

To receive in-network benefits for emergency care, follow these steps:

If possible, contact your PCP immediately for advice and instructions.

• Your PCP or the physician designated in his or her absence can be reached 24 hours a day. Be sure you are contacting the correct PCP. For example, if a covered child has an emergency condition, contact the child's PCP, not yours. If you can't reach the PCP, call Member Services for assistance.
• The PCP will either advise you by telephone on what to do, suggest you come to the office, or recommend that you go immediately to an emergency facility.
• Any emergency care authorized by the PCP is covered in full with no copayment.
• If the condition is of an obviously life-threatening nature
  • Seek treatment at the nearest emergency facility.
  • Notify your PCP within 48 hours of the emergency treatment regardless of whether you are admitted to the hospital. A family member or friend can call if you are not able to make the phone call.
  • Your PCP must authorize any continued medical services.

If you follow this process and the condition qualifies as an emergency, the emergency care is covered in full with no copayment. Managed Choice POS provides network coverage while you are temporarily outside the service area if you require emergency medical attention. You must notify your Primary Care Physician or Member Services within 48 hours of the emergency treatment and your PCP must authorize any continued treatment.

If you go to an emergency facility without authorization from your PCP and the condition is not considered a medical emergency, only out-of-network benefits will be available. Some examples of conditions usually not considered to be emergencies include:

• Colds, influenza, coughs
• Earache
• Pink eye
• Sprains.

To be eligible for in-network benefits, any non-emergency care you receive must be authorized by your PCP before you receive treatment.

Whenever you use the emergency room or other emergency facility, present your Managed Choice POS ID card at the time of service. The card contains emergency instructions.

If the emergency condition is so severe that you are not able to notify your PCP, a family member or medical emergency provider’s representative can make the call for you. Failure to notify the PCP within 48 hours of emergency treatment can result in ineligibility for network benefits although extenuating circumstances will be taken into consideration.

In situations where the PCP was not contacted before treatment was received, the Aetna claims office may process the expense for treatment as an out-of-network service. If you feel the emergency treatment qualifies for in-network benefits, you should call Claims Inquiry after you receive the explanation of benefits. You may be asked to provide additional details concerning the emergency situation over the phone or in writing.

Ambulance service is covered for emergency transportation to the nearest hospital where adequate care can be provided.

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How Do You Receive Preventive Care and Alternate Care

The Managed Choice POS network benefits cover preventive services such as:

• Immunizations
• Routine physical exams
• Well-baby care.

You pay $10 for the office visit to the PCP.

Managed Choice POS network benefits also cover alternate care in full with the following maximums:

• Skilled nursing facility care up to a 365-day lifetime maximum
• Home health care up to a 240-day lifetime maximum
• Hospice care up to a 180-day maximum.

The alternate care must be prescribed through your PCP to be eligible for network benefits. If you exhaust your network benefits, your case may be a candidate for case management.

Private duty nursing is also covered if prescribed through your PCP.

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What Is Your Vision Benefit?

The Vision One discount program is available to Aetna U.S. Healthcare® members through Cole Vision® at no additional cost. This program may help you and your family
save on many eye care products, including eyeglasses and contact lenses, nonprescription sunglasses, contact lens solutions and accessories.

Now, Vision One also offers a discount on the laser vision correction procedure called Lasik (Laser In-Situ Keratomileusis).

Click here to view the Vision One© Discount Program (.pdf document).

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How Is Administration Reduced

With the Managed Choice POS network, your administrative requirements are kept to a minimum. In most cases, you will file no claims for benefits. The network provider takes care of the claims process.

In addition, your PCP is responsible for getting advance approval for:

• Hospitalization
• Surgery
• Diagnostic procedures
• Alternate care.

When you receive a network service, you may receive a statement showing the services you received and the cost of services. This statement is for your information only and does not require payment from you. A copy of the statement will be filed by the provider directly with Aetna for payment.

You may occasionally receive a bill for services in error. For example, tests or other special procedures performed in a hospital usually are billed separately from the hospital bill. If you receive a bill for network services, you should:

• Call Claims Inquiry to notify the customer service representative of the error.
• Send the bill to the Aetna claims office for payment to the provider.

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