How can I help
control health
care costs?
So lets talk about…
ID Cards
Benefits and Plan Overview
Cost of Health Care
Value-Based Tools and Programs
Online Tools
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ID Cards
One Call – One Contact
We are committed to making your
Aetna experience positive and
productive.
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Access to ID Cards
3
easy ways to get an ID card
1. Aetna Mobile App
Pull up your Aetna
medical ID Card on your
phone or device any time
you need it.
2. Aetna Navigator
Log into your secure
Navigator and print an
ID card.
3. Contact Aetna
Call 800-222-9205
and they can assist
with ordering a card.
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So lets talk about…
ID Cards
Benefits and Plan Overview
Choosing Wisely
Being a smart health care consumer starts
with choosing the right plan for you and
your family.
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2015-2016 Current Benefit Plan Overview
CURRENT PLANS
Plan Deductible
Family Deductible
OOP Maximum
Family OOP Max.
AC1HD
Individual
AC1HD
w/dep
Open Access
Select
Select w/AWH
AC2
$2,500
$5.000
$1.200
$1,200
$1,000
N/A
N/A
$3,600
$3,600
$3,000
$6,450
$12,900
$6,600
$6,600
$6,600
N/A
N/A
$13,200
$13,200
$13,200
Yes – 80% of
reduced allowable
Yes – 60% of
reduced
allowable
Out of Network (OON)
Emergency Care (ER)
Yes – 80% of
reduced allowable
Out of Network (OON)
(excluding ER care)
Yes – 60% of
reduced allowable
In Network
Alternatives to ER
Teladoc & Urgent Care
Teladoc - $40 after
ded. & coinsurance
Urgent Care – 80%
after deductible
Yes – 80% of
Yes – 80% of reduced
reduced allowable
allowable
NO OON
BENEFITS
Teladoc - $40 after Teladoc – covered
ded. & coinsurance 100%, no copay
Urgent Care – 80% Urgent Care – 100%
after deductible
after $50 copay
Yes – 60% of
reduced allowable
NO OON
BENEFITS
Teladoc – covered
100%, no copay
Urgent Care – 100%
after $50 copay
Yes – 60% of
reduced allowable
Teladoc – covered
100%, no copay
Urgent Care – 100%
after $50 copay
Physician Co-pays
NO
NO
$30
$30
$30
Specialist Co-pays
NO
NO
$60
$60
$50
Bariatric Surgery
Bariatric copay
(See specific plan
details)
Bariatric copay
(See specific plan
details)
NOT COVERED
Bariatric copay
(See specific
plan details)
NOT COVERED
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Did you know…
AC1HD
Individual plan
• Only preventative services are paid at 100% prior to deductible.
• All other charges are subject to plan deductible.
• If you are in this plan with self only coverage and have a baby, you are automatically
moved to the $5000 Deductible Plan.
• If you start on this plan and then delete dependents, you do not get credit for any
deductible or out of pocket maximums. (Unless in the case of death.)
• This plan has out of network benefits, however, at a reduced co-insurance percentage of
a reduced allowable amount.
AC1HD
with dependents
• Only preventative services are paid at 100% prior to deductible.
• All other charges are subject to plan deductible.
• The deductible and out of pocket maximums can be met by one or more family
members.
• This plan has out of network benefits, however, at a reduced co-insurance percentage of
a reduced allowable amount
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Did you know…
OA Select
Open Access Select Plan
• Where you live determines if you are placed in the Select Plan with AWH or without
AWH.
• If you choose the Select Plan and do not live in one of the counties below, this is your
plan. You do NOT get to pick THIS Select Plan if you live in a county listed below.
• Bexar, Collin, Comal, Dallas, Denton, Ellis, Ft. Bend, Guadalupe, Harris, Hays, Kendall,
Montgomery, Parker, Rockwall, Tarrant, Travis or Williamson Counties.
Select w/AWH Aetna Whole Health (ACOs)
• AWH=Aetna Whole Health - These Select plans support the member with their own
team of doctors and facilities. Referrals are not necessary as long as you stay in their
network. A PCP is recommended, but not mandatory.
• If you have a child away at college or child who lives in a different city, this is probably
not the plan for you.
• Most coverage outside your service area is not covered. You only have coverage for
emergencies (ER) and Teladoc.
• This plan has a Gold colored ID Card to help providers distinguish your plan.
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Accountable Care Networks
What is Accountable
Care?
• Collaboration and risk
sharing between Aetna
and Provider organizations
Collaboration
Patient
Focused
Care
• Delivery of medical cost
savings and better patient
outcomes
• Highly coordinated and
efficient care through
clinically integrated
networks
Accountable
Care
Networks
Health
Information
Technology
Quality
and
Efficiency
Risk
Sharing
Wellness
And
Prevention
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ActiveCare Select/Aetna Whole Health
How Does ActiveCare Select/Aetna Whole Health Work?
• Where you live makes a difference! If you enroll in ActiveCare Select AND you live
in one of the counties that are supported by an Accountable Care Network, you will
be enrolled in the ActiveCare Select/Aetna Whole Health plan.
─ Baylor Scott & White Quality Alliance (Collin, Dallas, Denton, Ellis, Parker,
Rockwall and Tarrant
─ Memorial Hermann (Ft. Bend, Harris and Montgomery)
─ Baptist Health System/Health Texas Medical Group (Bexar, Comal, Guadalupe and Kendall)
─ Seton Health Alliance (Hays, Travis and Williamson)
Important Information about the Plan
• The providers you see make a difference!
• Using doctors and providers in the Accountable
Care Network will help you maximize your
benefits.
• Emergency Room care is an exception!
Accountable
Care Option
It is all
About
You
And
Your
Care
Team
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Caremark Pharmacy Specialty Medications
Effective December 1st 2014, specialty medications must be
purchased through Caremark specialty pharmacy using the
pharmacy benefit.
Caremark
Examples of Rx
Self
Administered
Clinician
Administered
Medications
• Caremark will work with the member
to have the medication delivered to
the pharmacy of their choice or to
the members home.
• Caremark will work with the member
and physician to have the medication
delivered to the MD office, or to the
infusion site/home health agency.
•
•
•
•
•
•
Multiple Sclerosis
Hemophilia Factors
Growth Hormones
HIV , Hepatitis C
Oral Chemotherapy
Transplant; anti-rejection
• IVIG
• Remicade, Enbrel, Humira,
Stellara
• Immune Globulins
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Avoiding and Handling Surprise Bills
• Sometimes members receive surprise bills after receiving care, but there are
ways to avoid getting a surprise bill:
• When planning for medical care, make sure all doctors, facilities, laboratories,
and imaging centers are in the TRS-ActiveCare network.
• An out-of-network provider could send the patient a “balance bill” for the
charges not paid for by TRS-ActiveCare.
• Get the required referrals and prior authorizations before receiving care.
• Find out your costs before getting care.
Use the online cost estimator through Aetna
Navigator or call Aetna directly.
• If you get a surprise bill, Aetna is here to help.
• Compassion Consultants can contact the
providers to try to negotiate on a
member’s behalf.
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New Providers in the Network
Anesthesia Update
• On January 1, 2016, the US Anesthesia group joined the network,
expanding access to approximately 800 additional providers in the
DFW area.
• Claims since September 1, 2014 will be re-processed as innetwork claims.
• Members will receive an updated explanation of benefits.
• The project will take a couple months to complete.
Baylor, Scott & White Quality Alliance (ACO) update
• On November 1, 2015, the Methodist facilities and employed doctors
joined the Baylor ACO network.
• This expanded the network in south Dallas, Mansfield, and north
Dallas.
• With this addition and the June addition of Tenet, the Baylor ACO will
contain 45 hospitals and many new physicians.
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So lets talk about…
ID Cards
Benefits and Plan Overview
Cost of Health Care
…..broader strategy to encourage better care, smarter
spending, and healthier people by paying for what
works, unlocking health care data, and finding new
ways to coordinate and integrate care to improve
quality.
CMS News March 8
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Cost of Health Care
• Many factors affect health care costs, and
TRS is not immune to these influences.
Fee-forservice
model
• TRS is working with Aetna to
• Help those with chronic conditions
manage them effectively
Chronic
illness
• Encourage health and wellness
Health Care
Costs
• Educate members about how to be
smart health care consumers
• TRS is working with a joint interim
committee of the Texas Legislature to
study
• The affordability of TRS-ActiveCare
Disease vs.
healthoriented
system
Complex
treatments
Aging
population
High-cost
drugs
• The sustainability of TRS-Care
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Health Care Costs
What You Can Do
TRS health coverage is not insurance; it is a finite resource shared by
members, and you can help ensure it is used wisely.
• Get healthy and stay healthy.
• Be a smart health care consumer.
• Continue to see doctors, hospitals, facilities, and labs
that are in the network.
Out-of-network
6%
• Use generic drugs when available.
• Use the online Aetna Navigator tool to see which
providers are in network and to get cost estimates for
medical care you’re planning.
• Use urgent care facilities and walk-in clinics instead
of emergency rooms, including free-standing
emergency rooms.
Claims Paid
In-network
94%
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Health Care Costs
Emergency Room Visits and Costs
• More than one-third of emergency room visits were classified as non urgent.
• Emergency rooms cost you and the plan more – even free-standing ER’s.
• 13 times more expensive than urgent care and 33 times more expensive than
a walk-in clinic.
Emergency Room Visits
Emergency Room Costs Compared to
Other Sites of Care
$2,500
20.0%
25.8%
$2,000
$1,500
$1,000
16.9%
$500
37.3%
$0
Not classified
Medical emergency
Non urgent
Trauma
Emergency
Room
Amount Plan Pays
Urgent Care
Walk In Clinics
Amount Employee Pays
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So lets talk about…
ID Cards
Benefits and Plan Overview
Cost of Health Care
Value Based Tools and Programs
We help members
no matter how their health changes — over
time and across providers — in ways that make
sense and meet their unique needs.
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Care Advocate Team
Care Management at its best!
Case mangers help members to:
• Improve skills in self management
• Transition/coordinate among
multiple providers/levels of care
• Discuss over/under or misuse
of health care system
• Coordinate end-of-life care needs
and life-limiting disease care needs
• Maximize effective use of health
plan benefit
• Help manage acute exacerbation
of chronic illness
14,500
inpatient
admissions
reviewed
18,000 Case
Management
cases
opened
Referrals to
Maternity
program
11,000 Post
Discharge
Calls made
2,500
Preadmission
Calls
700 Social
Worker
consults
Disease
Management
Referrals
• Reduce avoidable costs
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What is the Aetna Health Connections
Disease Management program?
SM
A program that identifies
and monitors members with chronic
conditions and effectively engages
them to close gaps in care* by:
•
•
•
Using change-management techniques
combined with evidence-based clinical tools
Developing individualized actions that motivate and
empower members to engage in behaviors that reduce
their health risks
Engaging physicians when critical care gaps are identified
Designed to help
improve health
outcomes and lower
costs for plan
sponsors and
members.
* “Gaps in care” refers to a broad range of potential needs that prevent members from attaining their optimal health and wellness
potential, e.g., absence of a caregiver in the home, inability to fill prescriptions due to problems with co-pays, and difficulty finding a
home care company to provide services. The term will be used in this context throughout this presentation.
Aetna Inc.
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Online health coaching programs offer
broad support
Supports chronic
conditions and
wellness
including:
Online
•
•
•
•
•
•
•
Asthma
Cholesterol control
Diabetes management
Blood pressure control
Healthy back
Stress less
•
•
•
•
•
Tobacco cessation
Healthy eating
Fitness
Sleep
Weight
management
Healthy living
health
coaching
programs
Aetna Inc.
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Informed Health Line – 24/7 Nurse Line
A 24-hour information line for your
health questions
5,044 Calls
last year
Talk to a registered nurse anytime
With the Informed Health Line, you can
speak to a registered nurse about health
issues that are on your mind —
Most calls
whenever you need to.
after 4pm
Plus —
• It’s toll-free.
• You can call as many times as you
7,303
need — at no extra cost.
Issues
• Your covered family members
Identified
can use it too.
1-800-556-1555
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Teladoc
An easier interaction
is a better interaction
Request consult
Talk to a doctor
Issue resolved
A convenient, coordinated experience
Average call back for on-demand consult is 16 minutes*
Integration with plan administrator for claims and eligibility
Real-time member responsibility determination
*Guaranteed
call back for
on-demand consult
within 1 hour or
consult is FREE!
Rx sent to local pharmacy (if needed)
Teladoc Health record automatically updated
1-855-835-2362
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Beginning Right Maternity Program
A program to give your baby a healthy start
As part of your Aetna plan, you get the
Beginning Right maternity program. It can
help you and your baby grow healthier
together.
You can:
• Learn what’s best for a healthy pregnancy
• Lower your risk for early labor
• Stop smoking for good
• Cope with postpartum depression
* Receive a $100 gift card to Babies R Us
Visit us at www.aetna.com
or call us at 1-800-CRADLE-1 (1-800-272-3531)
when you become pregnant.
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Live Healthy America
Wellness Campaigns
An exciting and fun opportunity brought to you by TRS-ActiveCare and
Aetna. This wellness program is simple, free of charge, and open to any
TRS-ActiveCare employee on Aetna's medical plan. Earn wonderful prizes
while getting healthy.
Live your life like every moment matters! Join the next challenge and
become a healthier you!
Successful First
Campaign completed
in Nov. 2015. 2,707
individuals registered;
639 teams.
12 Schools
qualified for
$2,000 reward
Second Campaign:
Going strong! Over
800 teams
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So lets talk about…
ID Cards
Benefits and Plan Overview
Cost of Health Care
Value Based Tools and Programs
Online Tools
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Member Website
www.trsactivecareaetna.com
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Navigator Website
www.aetnanavigator.com
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Doc Find Website
www.trsactivecareaetna.com
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So lets talk about…
New BA Service Model
Benefits and Plan Overview
Cost of Health Care
Value Based Tools and Programs
Online Tools
Thank you!
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