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FAQs
Medical - Frequently
Asked Questions
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General Questions
Preferred Provider Questions
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How many times do I have to fill out one of those medical update
forms?
The Plan requires that an
Annual Medical/Dental Update Form be updated
once every twelve months or whenever the
patient’s information changes. For example, the form should be
updated when a spouse’s medical insurance changes through his or her
employer. If you cannot remember when each family member’s form
expires, and you anticipate using the Plan within the year, you may
download the form in January and fill one out for each covered
family member.
An updated
Annual Medical/Dental
Update Form for
the patient must be on file at the Administrative Office for any claims to be
processed. If the Annual Medical/Dental Update Form is not current,
the participant will be requested to fill one out and the claim will
be not be paid until the form is completed. The most common
cause for a delay in processing a claim is that the patient does not
have a current Annual Medical/Dental Update Form on file.
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How long do I have to
file a claim?
The Plan accepts claims for medical services
for twelve months from the date of service.
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What is
pre-authorization and why does my procedure
need to be pre-authorized?
The Plan will only cover procedures and treatments that are
medically necessary. Pre-authorization is a medical review by
an independent group of physicians to determine whether a procedure
or treatment is medically necessary. The Plan has contracted with
Aetna to perform this function.
Click on the link below for more information:
Medical
Pre-Authorization
To pre-authorize your procedure, have your physician or health
care provider call Aetna at 1-888-632-3862 option 3.
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How do I add a dependent?
If you are currently enrolled in a Plan that
covers family members, simply update your
Enrollment Form
and submit copies of the following
documents, as appropriate:
- State-issued Marriage certificate
- State-issued Birth certificate
- Adoption papers signed by a judge
- HIPAA certificate showing change in other
insurance coverage
- Court orders in case of divorce decree and/or
any other legal documents specifying the order to provide medical
support for a dependent.
For an overview on eligible dependents, please
see Who’s Eligible.
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What is the time frame I have to add a dependent to my plan?
If you acquire a
new Dependent, you should complete a new enrollment form and submit
it to the Administrative Office within 60 days. In no case will
coverage for new Dependents apply before the later of the date the
individual became your dependent or the date that is 365 days before
the date the Administrative Office receives the enrollment form.
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How do I mail order my
prescriptions?
Mail order is a cost-effective way to obtain
medication you take on an on-going basis. Prescriptions are filled for
up to 90 days. To fill a new prescription, you must submit an order form and
provide an original doctor’s script which indicates whether a brand
name drug or a generic is appropriate. You can then refill the
prescription by phone, mail, or via the internet at
www.caremark.com. For further information see Prescription
Drugs.
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Do my
prescription co-pay apply toward my medical deductible?
No, your prescriptions DO NOT apply to your
medical deductible.
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Are travel expenses covered?
Travel to the nearest facility will be reimbursed
by the Plan if treatment is unavailable locally and it is medically
necessary. If the member traveling is a minor, the Plan will
reimburse travel for one parent or guardian to accompany the minor.
The Plan will also reimburse travel for one companion to assist an
adult member if the member is incapacitated due to a medical condition
and will need assistance.
Please note that the Plan does not reimburse for
ground transportation or room and board. This means that car rentals,
motels/hotels, parking, and cab fares are not covered expenses.
For reimbursement for travel expenses, you must
submit a letter of medical necessity from your current physician, a
copy of the ticket(s) with the dates and costs of travel, and the
boarding pass(es) as proof that the travel took place. Travel
benefits are subject to medical deductible and eligibility
requirements.
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What is a subrogation agreement and why do you want me to sign it?
In general, subrogation is the substitution of
one creditor for another. Each member of the Plan is subject to
subrogation if they are involved in a matter where a third party may
be liable for medical expenses. If the Plan pays medical expenses for
you and you subsequently receive reimbursement from a third party, you
are obligated to reimburse the Plan for the medical expenses the Plan
has paid.
By
signing a subrogation agreement you assure the Plan that you will
reimburse the Plan its expenses when your settlement is received. If
you are represented by legal counsel, your attorney must also sign the
subrogation agreement. Please see the Subrogation section of the
Summary Plan Document for details.
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May I use the Wellness and Minor Care Plan for treatment of
a long-term condition?
No, the Wellness and Minor Care program is not for treatment
of chronic or long-term conditions such as diabetes or
asthma. You are welcome to use the providers that
participate in the Wellness and Minor Care program for
treatment of a chronic condition; however, your claims must
be processed under the provisions of the major medical plan.Top
How much do I pay when using the Wellness and Minor Care Plan?
The cost for service is
$20
per person per visit, or $50 if three or more family members visit
the clinic at the same time for services. Charges for services will
not apply to your annual deductibles, reimbursement percentages, or
out-of-pocket limits.
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What is the Summary of Benefits and Coverage (SBC)?
This document was
first provided to you as a requirement by the Patient
Protection and Affordable Care Act.
Whenever there are
changes to the Plan that affect the information in the
Summary of Benefits and Coverage (SBC),
the Administrative Office must re-issued it to you. In 2013, you
will note substantive changes in the mental health, behavioral
health, or substance abuse section of the SBC. Effective January 1,
2014, benefit for outpatient mental health, behavioral health, or
substance abuse services are paid in the same manner as the majority
of other outpatient physician services provided under the Plan;
subject to the Plan deductible and out-of-pocket maximum. Benefits
for inpatient mental health, behavioral health or substance abuse
services are paid in the same manner as other inpatient hospital
treatment under the Plan, and are subject to the inpatient
deductibles, out-of-pocket maximum and preauthorization
requirements.
The SBC does not
replace your Summary Plan Description (SPD).
The format of the SBC is mandated by federal law and only provides
limited information regarding the benefits available to you through
the Plan. In particular, the coverage examples in the SBC are
designed by the federal government and illustrative only-they should
not be taken as a guarantee of charges that the Plan will cover for
any particular individual. If you
have specific questions regarding your health benefits, please refer
to your SPD, or contact the Administrative Office.
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What is the penalty for using a non-preferred provider (within the
Municipality of Anchorage)?
If you use a health care provider within the Municipality
of Anchorage that is a not a preferred provider, the Plan will base
your reimbursement on the preferred provider rate and will then
reduce your regular reimbursement percentage by 20% for the first
$50,000 in covered charges. In addition to these
reductions, a $1,000 penalty will be imposed to each inpatient
admission to a non-preferred provider.
For example, you live in Anchorage and need to
have outpatient physical therapy. The preferred provider charges the Plan
the negotiated rate of $100 for this type of treatment. A non-preferred provider in Anchorage charges $200 for this type of treatment. You have already
met your deductible for the year and the Plan usually reimburses at
85%.
If you have this treatment at the preferred
provider, the Plan will pay $85 ($100 X 85%). Your out-of–pocket
expense will be $15.
If you have treatment at the non-preferred
provider, the Plan will pay $65. First, the $200 expense is marked
down by 50% to $100, then the reimbursement
rate is reduced by 20%. ($100 X 65%) Your out-of-pocket expense
will be $135. For further examples of out-of-network
penalties, review
Using Preferred Providers - Municipality
of Anchorage.
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What
area does the Municipality of Anchorage include
The Municipality of Anchorage is comprised of the area
from Girdwood to the Knik River Bridge including the Anchorage bowl
area.
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Who are my preferred providers in the Municipality of Anchorage?
Your preferred providers within the Municipality of
Anchorage are as follows:
|
Service Needed |
Preferred Provider |
| Inpatient hospital
stays |
Alaska Regional Hospital |
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Outpatient x-ray services (including MRI, CAT scan,
mammogram, sonogram) |
Alaska Regional Hospital
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Outpatient laboratory |
Alaska Regional Hospital |
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Outpatient surgery |
Alaska Regional Hospital
Surgery Center of Anchorage |
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Emergency room (when possible) |
Alaska Regional Hospital |
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Sleep study tests |
Alaska Regional Hospital |
| Physical therapy services |
Chugach Physical Therapy
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| Occupational
therapy services |
Chugach Physical Therapy
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How
do I know where my labs and x-rays are being sent?
Ask! It is your responsibility, as a plan
participant, to educate your physician(s) and medical care
providers, as well as your dependents, regarding your preferred
providers. Let your physician know who your preferred
providers are and he/she will make arrangements for labs and x-rays
to be performed at your preferred provider.
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What is Aetna's Choice POS II ?
Aetna's Choice POS II is a nationwide
group of contracted preferred providers that offer considerable
discounts to the Plan for use of their facilities, groups, and
doctors. When you select a preferred provider from the Aetna's
Choice POS II network, you , your dependents, and the Fund will have
access to discounted pricing from providers that are part of the
Aetna network. You may review
Aetna's Choice POS II
website, to find a provider near you.
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What is the penalty for using a non-preferred provider (outside the
Municipality of Anchorage)?
The Plan uses Aetna's Choice POS II. If you use
a facility that is not Aetna's Choice POS II and it is within 25
miles of a Aetna's Choice POS II provider, the Plan will reduce your
reimbursement rate by 20%. You can search for a Aetna's Choice POS
II provider near you on
Aetna's Choice POS II
website.
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Is Primary
Care Associates a preferred provider?
Primary Care
Associates is not a preferred provider, but is a provider for the
Wellness and Minor Care
program. Primary Care Associates has agreed to reduced
rates on other services available at their Anchorage and Eagle River
clinics. For example, if you seek treatment at Primary Care
Associates for chronic services covered under the major medical
plan,
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you will save money because
your out-of-pocket costs will be lower in most cases,
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and you will not have to deal
with any usual and customary restrictions.
Please
be aware that HealthSouth Surgery Center, HealthSouth Diagnostic
Center, and HealthSouth Physical Therapy have offices in the same
building as Primary Care Associates, but they are non-preferred
providers for outpatient hospital services. Primary Care
Associates recognizes Alaska Regional Hospital and Chugach Physical
Therapy are the Preferred Providers for inpatient and outpatient
hospital services for our Plan.
You may obtain treatment
for minor illnesses and preventive care for adults and children age 2
and over using the
Wellness and Minor Care program.
The cost for service
is $20 per person per visit, or $50 if three or more family members
visit the clinic at the same time for services. Charges for services
will not apply to your annual deductibles, reimbursement percentages,
or out-of-pocket limits.
Deductibles and other
plan provisions of the major medical health plan will apply
if you obtain services
outside the scope of services available through the Wellness and Minor
Care Program.
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