In State POS Plan
for Active Employees and
Non-Medicare Retirees

 7/1/13 Summary of Benefits
 Benefit Comparison

We Heard You.
After speaking with many of our health plan participants over the past several months, it was clear you wanted a simpler plan. The State Employee Health Commission has made significant improvements to enhance your experience as a member. You will also find a chart, attached here, which will provide you with a side-by-side comparison of what the in network plan coverages are today and what they will be for July 1, 2013.

Plan Structure: We are moving from three levels of benefit to two. The preferred and referred levels have been combined into one in network benefit. You will still have out of network coverage as you do today.

No More Referrals: You will no longer need to get a referral from your Primary Care Physician for specialty care.

Deductibles: With one in network level of benefit, you will see only one calendar year deductible instead of two. The new in network calendar year deductible amounts are $500 individual or $1,000 family. Any amounts you have met towards your deductible through June 30, 2013 will apply to the new limits for July 1, 2013.

Maximum Annual Out-of-Pocket: Similar to deductibles, you will only have one out-of-pocket maximum for in network services. The new in network calendar year out-of-pocket maximum amounts are $2,000 individual or $4,000 family. The out-of-pocket max includes your deductible plus coinsurance. Any amounts you have met towards your out-of-pocket max through June 30, 2013 will apply to the new limits for July 1, 2013.

Routine Eye Exams: All covered members on your policy will be eligible for a routine eye exam once per calendar year regardless of age.

Ambulatory Surgery Centers: You are currently paying 15% coinsurance for these services once your deductible has been met. The coinsurance will be reduced to 5% for services provided at an ambulatory surgery center (non-hospital).

Urgent Care: The copay for urgent care received from an in network provider will be reduced from $100 to $25. This coverage will now be equal to that of an in network walk-in clinic. (Please note the emergency room copay will be $150 as of July 1, 2013.)

Diagnostic Lab Work: Your coinsurance limit for diagnostic lab work done at an in network facility (hospital & non-hospital) will be 10% after deductible.

Everyone will receive a new Aetna ID card as a result of these changes for 7/1/2013

What is staying the same?

  • Premiums
  • Office visit copays with your Primary Care Physician (PCP) and Specialist
  • Prescription drug copays
  • Many of your preventive services are still covered at no cost to you

Find a PCP or doctor in the network



Out of State POS Plan
for Active Employees and
Non-Medicare Retirees

 7/1/13 Summary of Benefits

How the Out of State Plan works
This plan gives you a choice between in-network and out of network providers and professionals. It’s important to keep in mind that your out-of-pocket costs are typically higher when you go to an out-of-network provider. You can visit your Primary Care Physician (PCP); or any network doctor, without a referral. You don’t have to choose a PCP, but you may want to.

Plan Highlights
Calendar Year Deductible: Individual $500 / Family $1,000
(Benefits are paid after the deductible has been met)
Coinsurance (coinsurance applies to most covered services)
  • In-Network 80%
  • Out of Network 60%
Calendar Year Out of Pocket Limit: Individual $2,000 / Family $4,000


Find a PCP or doctor in the network



Medicare AdvantageSM Plans


How the Medicare Advantage PPO Plan works
The Aetna Medicare Advantage PPO plan allows you the option to use doctors and hospitals that are in or out of the Aetna Medicare network. (Please refer to attached benefit summary for copay/coinsurance details as you may have a higher cost share when using out of network providers.)
  • For preventive services such as annual wellness exams and cancer screenings, you will be covered 100% with NO copay
  • You will receive additional benefits beyond Original Medicare A & B coverage
  • Discounts on health-related products and services
  • No referrals for covered services
  • Inpatient hospitalization covered 100%
How the Medicare Advantage PPO ESA Plan works
The Aetna Medicare Advantage PPO ESA plan will allow you the option to use doctors and hospitals that are in or out of the Aetna Medicare network. That means you can go to any provider that is licensed, is willing to accept the plan and eligible to receive payment from Original Medicare.
  • For preventive services such as annual wellness exams and cancer screenings, you will be covered 100% with NO copay
  • You will receive additional benefits beyond Original Medicare A & B coverage
  • Discounts on health-related products and services
  • No referrals for covered services
  • Inpatient hospitalization covered 100%



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