A number of changes are being made to the STRS Ohio Health Care Program effective Jan. 1, 2010. These changes have been communicated in STRS Ohio newsletters and in health care open-enrollment packets. The following questions and answers provide additional information about the 2010 changes and are divided into the following categories: general questions, Aetna Medicare Plan (PPO), Medical Mutual Plans and prescriptions. Updated information about the 2010 plan changes will continue to be added to our site, so please check back here frequently.
If you have specific coverage questions or issues regarding a claim, please call the plan administrators directly:
General Questions
What is the Medicare Modernization Act and how does it relate to my STRS Ohio health care coverage? (posted 10/15/09)
In 2003, Congress amended the original Medicare Act with the Medicare Modernization Act to bring people with Medicare more choices in health care coverage and better health care benefits beyond traditional Medicare. The Medicare Modernization Act created the Medicare Part D prescription drug program and the Medicare Part C Medicare Advantage program.
What are Medicare Advantage plans? (posted 10/15/09)
Medicare Advantage plans are health plan options approved by Medicare and offered by private companies. These plans are part of Medicare and are sometimes called “Part C” plans. Medicare pays a fixed amount for an enrollee’s care every month to the companies (for STRS Ohio, this company is Aetna) offering the Medicare Advantage plan. These companies must follow rules set by Medicare. They are not supplemental insurance. Enrollees must be entitled to Medicare Part A and be enrolled in Medicare Part B. If enrollees drop their Medicare Part B coverage and stop paying their Part B premium, the Centers for Medicare and Medicaid Services (CMS) will not allow their enrollment in a Medicare Advantage plan.
How is Medicare Advantage different from Medicare Part D? (posted 10/15/09)
Medicare Advantage provides medical coverage, while Medicare Part D provides prescription drug coverage. Sometimes Medicare Advantage plans are bundled with prescription programs. For STRS Ohio’s Aetna Medicare Plan (PPO), however, prescription drug coverage will continue to be provided separately through Express Scripts — at the same coverage levels offered through the Medical Mutual Basic and Plus plans.
Why did the Retirement Board approve a Medicare Advantage plan for 2010? (posted 10/15/09)
Over the past year, STRS Ohio, together with the other Ohio retirement systems, conducted an extensive review process looking at all market options. As a result of this process, the board approved offering the Aetna Medicare Plan (PPO), which provides improved coverage and lower costs to our Medicare enrollees and STRS Ohio.
What about President Obama’s stated intention to cut the subsidy to Medicare Advantage plans? How will this affect STRS Ohio? (posted 10/15/09)
The proposed cuts for 2010 have already been accounted for in the 2010 Aetna Medicare Plan (PPO). Aetna is prepared for and, in fact, thinks it is probable that subsidies will decline to traditional Medicare levels. However, the addition of wellness programs and strong case and care management tools, even in the short-term, should have beneficial results for our enrollees. If the government mandates future changes to the Aetna Medicare Plan (PPO) that no longer make this a cost-effective and attractive program for STRS Ohio’s enrollees, STRS Ohio is already prepared to revert to traditional Medicare and the STRS Ohio secondary plan coverage program.
How will health care reform being discussed in Washington affect the Aetna Medicare Plan (PPO) offered by STRS Ohio? (posted 10/15/09)
As most of us know, health care reform is of utmost importance to President Obama and he is committed to passage of a bill as soon as possible. Having said that, there are multiple bills that have been presented and debated in both the House and Senate. Much more debate is likely before a bill is approved. The implementation of any such bill is unlikely before 2011 or 2012. In either case, both STRS Ohio and Aetna expect the subsidy that the Centers for Medicare and Medicaid Services (CMS) currently pays for Medicare Advantage plans to decrease over the next few years until it matches or is less than the subsidy for traditional Medicare. Care management programs that are integral to STRS Ohio’s Medicare Advantage plan should sustain the program with competitive premiums. If not, STRS Ohio has the option to transition back to traditional Medicare and the STRS Ohio secondary plan coverage program.
What is the difference between an individual Medicare Advantage plan and the Medicare Advantage plan sponsored by STRS Ohio? (posted 10/15/09)
Generally, plans available through an employer, union or retirement organization are group plans, while plans offered to the general public, such as plans offered through AARP and other entities, are individual plans. The Aetna Medicare Plan (PPO) that is being offered through STRS Ohio is a group plan. STRS Ohio worked to develop a group plan that was based on the needs of our members. The open-enrollment period for individual Medicare Advantage plans is generally held between Nov. 15 and Dec. 31. This open-enrollment period is not connected to the STRS Ohio open-enrollment period, which is being held between Nov. 1 and Nov. 24, 2009.
Do the Ohio Public Employees Retirement System (OPERS) and the School Employees Retirement System (SERS) offer Medicare Advantage plans? (posted 10/15/09)
Yes. Both OPERS and SERS have successfully offered Aetna Medicare Advantage plans since January 2008.
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Aetna Medicare Plan (PPO)
Coverage Features
Does the Aetna Medicare Plan (PPO) cover everything that traditional Medicare covers? (posted 10/15/09)
Yes. The Aetna Medicare Plan (PPO) must provide enrollees with the same coverage they would receive under traditional Medicare. Therefore, the Aetna Medicare Plan (PPO) covers all medically necessary services covered under Medicare Parts A and B, although perhaps at a different level, plus some additional services not covered by traditional Medicare.
Are there copayments? (posted 10/15/09)
The Aetna Medicare Plan (PPO) offers copayments for some services. These copayments are not subject to the deductible or coinsurance. The services with copayments include: $15 copayment for physician services billed from the physician’s office; $35 copayment for urgent care; and $50 copayment for emergency room services.
Is there a deductible for hospital/medical services? (posted 10/15/09)
Yes, the Aetna Medicare Plan (PPO) deductible for hospital/medical services is $500. However, for physician services billed from the physician’s office, the deductible does not apply and instead there is a $15 copayment per visit. Additionally, the deductible does not apply to urgent care, where there is a $35 copayment, to emergency room services where there is a $50 copayment or to preventive care services, which are covered by the plan at 100%.
How is the annual out-of-pocket maximum calculated for hospital/medical services? (posted 10/15/09)
There is a $1,500 annual out-of-pocket maximum per enrollee for hospital/medical services. It is calculated by adding together the deductible, all copayments and the coinsurance amounts paid by the enrollee during the calendar year, up to $1,500. There is a separate annual deductible that must be met for prescription drug coverage.
What prescription drug coverage will be included with the new Aetna Medicare Plan (PPO)? (posted 10/15/09)
Prescription drug coverage will continue to be administered by Express Scripts. The prescription drug plan for the Aetna Medicare Plan (PPO) will be the same as what is offered through the Medical Mutual Plus and Basic Plans, plus includes a special program for diabetics (see next question). The Retirement Board approved prescription drug plan changes, effective Jan. 1, 2010, for the Aetna, Medical Mutual and Paramount plans. A summary of the prescription drug plan changes was included in the July Special Edition Health Care Program News. Enrollees will also receive information in their open-enrollment packet.
What is the value-based prescription program for diabetics available under the Aetna Medicare Plan (PPO)? (posted 10/15/09)
STRS Ohio’s Health Care Services staff has developed a pilot program that seeks to reduce hospitalizations and improve the health status for individuals with diabetes through improved medication compliance. Diabetes is the most prevalent chronic condition among STRS Ohio enrollees and one of the biggest cost-drivers of the STRS Ohio Health Care Program. Under this program, enrollees will be able to purchase Tier 1 or Tier 2 diabetic medications through mail service at reduced copayments. In addition, the $150 deductible will not apply to these medications. This is the one difference in the prescription drug program provided under the Aetna Medicare Plan (PPO) versus the Basic and Plus Plans.
What diabetic supplies are covered under the Aetna Medicare Plan (PPO)? (posted 10/15/09)
The Aetna Medicare Plan (PPO) covers the same supplies as those currently covered under traditional Medicare with the Plus and Basic Plans. This includes glucometers, test strips and lancets, which enrollees should continue to obtain through Express Scripts and NationsHealth.
How can I get more information on the Aetna Fitness Program available under the Aetna Medicare Plan (PPO)? (posted 10/15/09)
Enrollees can obtain information on Aetna’s Medicare Fitness Program by visiting its Web site at http://afp.wholehealthmd.com.
How can I find a participating gym or fitness center? (posted 10/15/09)
Enrollees can call Aetna toll-free at 1-877-243-3004 or visit http://afp.wholehealthmd.com to locate fitness centers in their area.
Will my medical provider accept the Aetna Medicare Plan (PPO)? (posted 10/15/09)
The best way to determine if your medical provider accepts the Aetna Medicare Plan (PPO) is to contact the provider directly. If the provider has any questions, he or she should call the Aetna Provider Service Center at 1-800-624-0756. Aetna will be contacting providers to educate them on the Aetna Medicare Plan (PPO) that STRS Ohio is putting into effect. This outreach program proved highly effective for SERS and OPERS when they began offering their Medicare Advantage Plans with Aetna.
Am I covered if I travel outside of the United States? (posted 10/15/09)
You will be covered for emergency services while traveling outside of the United States; however, this does not include urgent care services. An example might be if you break your leg and go to an emergency room for treatment. This is covered. If you sprain your ankle and go for treatment, this would be considered urgent care and would not be covered.
How does the Aetna Medicare Plan (PPO) impact the optional Vision Service Plan (VSP) and Delta Dental coverage offered through STRS Ohio? (posted 10/15/09)
The Aetna Medicare Plan (PPO) offers one free annual vision exam. Generally, providers bill routine vision exams under the codes of 92002 – 92015, which are considered preventive and are covered. If a provider submits only the CPT code of 92015, the exam services would be considered refractive only and would not be covered under the Aetna Medicare Plan (PPO). These services would, however, be covered under the optional Vision Service Plan coverage. The Aetna Medicare Plan (PPO) does not cover any additional dental services. If an enrollee elects to participate in the optional vision or dental plans sponsored by STRS Ohio, the Aetna Medicare Plan (PPO) will not impact that coverage.
Since the Aetna Medicare Plan (PPO) offers a discount on vision eyewear, will STRS Ohio allow me to cancel my optional vision plan through Vision Service Plan (VSP)? (posted 10/15/09)
No, enrollees must remain in the optional vision plan through VSP until conclusion of the current two-year period, which ends Dec. 31, 2010. The coverage under the optional vision plan is comprehensive and covers exams, lenses and frames, while the vision program under the Aetna Medicare Plan (PPO) only offers one annual vision exam and discounts on eye care items and services.
Eligibility
If I do not have both Medicare Parts A and B, can I enroll in the Aetna Medicare Plan (PPO)? (posted 10/15/09)
No. You are not eligible to enroll in the Aetna Medicare Plan (PPO). This is because the cost of the Aetna Medicare Plan (PPO) for individuals without both Medicare Part A and Part B coverage would have exceeded the 2010 Plus Plan cost by $100 a month. Therefore, in 2010, STRS Ohio will offer, in addition to the Basic Plan, the Plus Plan option through Medical Mutual to individuals without both Medicare Parts A and B because they cannot enroll in the Aetna Medicare Plan (PPO).
Will “split Medicare families” be permitted to enroll in the Aetna Medicare Plan (PPO)? (posted 10/15/09)
No. Split Medicare families (family accounts that include Medicare and non-Medicare enrollees) are not eligible to enroll in the Aetna Medicare Plan (PPO). Since not all the family members who want to enroll meet the eligibility requirements for the Aetna Medicare Plan (PPO), STRS Ohio will offer the Medical Mutual Basic and Plus Plans in lieu of the Aetna Medicare Plan (PPO).
What plan options are available when the benefit recipient has Medicare Parts A and B and the spouse turns age 65? (posted 10/15/09)
It depends on the Medicare status of the spouse. If the spouse turns age 65 and has Medicare Parts A and B, the couple could enroll in the Aetna Medicare Plan (PPO) or the Medical Mutual Basic Plan. However, if the spouse turns age 65 and is only eligible for Medicare Part B, the couple’s plan options are the Medical Mutual Basic Plan or the Medical Mutual Plus Plan.
If a benefit recipient and spouse are age 65 with Medicare Parts A and B and they want to enroll a sponsored dependent, are they eligible for the Aetna Medicare Plan (PPO)? (posted 10/15/09)
If the sponsored dependent does not have Medicare Parts A and B, the family is ineligible to enroll. To be eligible for the Aetna Medicare Plan, all enrolled family members must have Medicare Parts A and B.
What plan options will enrollees have when they turn age 65 and enroll in Medicare Parts A and B? (posted 10/15/09)
When enrollees provide STRS Ohio with proof of their enrollment in Medicare Parts A and B, STRS Ohio will automatically move them from Medical Mutual to the Aetna Medicare Plan (PPO). If they prefer, they may also enroll in the Medical Mutual Basic Plan. Individuals who were in a AultCare, Kaiser or Paramount plan may remain in that plan or they may choose to enroll in the Aetna Medicare Plan (PPO) or Medical Mutual Basic Plan.
What if I do not want to remain enrolled in the Aetna Medicare Plan (PPO)? (posted 10/15/09)
The Centers for Medicare and Medicaid (CMS) requires Medicare Advantage plans to allow enrollees to disenroll, if desired. During the open-enrollment period from Nov. 1 – 24, 2009, the deadline to disenroll from the Aetna Medicare Plan (PPO) is Nov. 24. Beginning Jan. 1, 2010, enrollees may call STRS Ohio anytime to terminate coverage in the Aetna Medicare Plan (PPO). STRS Ohio must receive termination requests by the 15th of the month to become effective the first day of the following month. Enrollees who terminate from the Aetna Medicare Plan (PPO) would be eligible to enroll in the Medical Mutual Basic Plan or a local fully insured plan (AultCare, Kaiser or Paramount), if available in their area.
Do I give up my Medicare coverage when I join the Aetna Medicare Plan (PPO)? (posted 10/15/09)
No. The Aetna Medicare Plan (PPO) is another plan option available under Medicare. The Aetna Medicare Plan (PPO) is Medicare but Medicare through a Medicare Advantage plan. STRS Ohio designed the Aetna Medicare Plan (PPO) to include the same coverage provided under traditional Medicare Parts A and B and the STRS Ohio Plus Plan, with additional improvements added to the coverage. Enrollees are eligible for the Aetna Medicare Plan (PPO) as long as they are entitled to Medicare Part A and continue to pay their Part B premium.
Do I still have to pay my Medicare Part B premium? (posted 10/15/09)
Yes. Medicare does not allow individuals to enroll in a Medicare Advantage plan like the Aetna Medicare Plan (PPO) if they do not enroll in Medicare Part B and pay their Medicare Part B premium. If you terminate your Medicare Part B enrollment and discontinue paying your Medicare Part B premium, you will no longer be enrolled in the Aetna Medicare Plan (PPO).
Will Medicare enrollees in the Health Care Assistance Plan (HCAP) be moved to the Aetna Medicare Plan (PPO)? (posted 10/15/09)
The majority of HCAP enrollees will remain in their current 2009 plan, except for those enrolled in an Aetna plan. These enrollees will be moved to the equivalent Medical Mutual plan. Medicare HCAP enrollees with Medicare Parts A and B who wish to enroll in the Aetna Medicare Plan (PPO) may elect to do so during the STRS Ohio open-enrollment period.
What happens if I am already enrolled in another Medicare Advantage plan? (posted 10/15/09)
The Centers for Medicare and Medicaid Services (CMS) does not allow enrollment in more than one Medicare Advantage plan. If you are already enrolled in another Medicare Advantage plan, you will automatically be disenrolled from the “oldest” Medicare Advantage plan and enrolled only in the most current, which will be the Aetna Medicare Plan (PPO). Likewise, if you enroll in another Medicare Advantage plan after Aetna, you will be disenrolled from the Aetna Medicare Plan (PPO).
Administration & Communication
Will I still have two ID cards for my medical coverage (Medicare and the STRS Ohio health care plan ID card)? (posted 10/15/09)
No. You will receive a single Aetna Medicare Plan (PPO) ID card that you will show to your provider. You should still retain your Medicare ID card with your personal records, but you will no longer need to present that card for your medical care. Your provider will only need to submit the claim to Aetna (rather first to Medicare and then to Aetna). You will not have to coordinate claims between two medical plans. Each member enrolled in the Aetna Medicare Plan (PPO) will receive a new medical ID card from Aetna.
Additionally, because prescription drug coverage under the Aetna Medicare Plan (PPO) is provided through Express Scripts, enrollees will also continue to have a separate prescription drug ID card, just as they do today.
What will my Aetna Medicare Plan (PPO) ID card look like? (posted 10/15/09)
The name on your Aetna Medicare Plan (PPO) ID card will match the name that the Centers for Medicare and Medicaid Services (CMS) houses in its system. This is a CMS requirement. For example: STRS Ohio sends an eligibility file with Harry Smith listed. He is listed as Harold R. Smith within the CMS system. CMS will send this information back to Aetna. Aetna will update Harry Smith's name in its system to now reflect Harold R. Smith, per CMS direction, as Aetna must now match CMS for proper record keeping. Harold R. Smith will appear on the Aetna ID card. The front of the ID card says “Aetna Medicare” in the top left corner and includes the STRS logo in the top right corner. The back of the ID card includes important phone numbers and the address where providers should submit claims.
This is an example of the Aetna Medicare Plan (PPO) ID card:
When I have a claim, will I receive an Explanation of Benefits (EOB) from Aetna? (posted 10/15/09)
Yes. Enrollees will receive an Explanation of Benefits (EOB) after all services. Enrollees may contact Aetna with any EOB-related questions.
What else will I receive from Aetna? (posted 10/15/09)
After the Centers for Medicare and Medicaid (CMS) approves your enrollment in the Aetna Medicare Plan (PPO), you will receive the following:
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Aetna will send you a “Welcome Aboard” letter about 10 days after CMS approves your enrollment in the Aetna Medicare Plan (PPO). Remember, you are not officially enrolled in this plan until CMS approves your application.
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Aetna will send your ID cards about two weeks after receiving your enrollment approval from CMS. If you need to obtain services before your ID card arrives, present the “Welcome Aboard” letter as proof of coverage
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Aetna will send you an Evidence of Coverage booklet approximately 20 days after receiving enrollment approval from CMS. This booklet details your hospital and medical coverage under the plan.
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After your enrollment is approved, a health care professional from CareCall, an affiliate of Aetna, will call to ask you some short questions about your health. If CareCall can’t reach you by phone, they will send you a survey in the mail. The goal of this survey is to help you and your doctor better manage your health. The federal government requires Aetna to conduct this survey.
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Aetna will periodically send you helpful reminders about preventive care tips and topics.
How will my claims be handled if I turn 65 in the middle of the year and then move to the Aetna Medicare Plan (PPO)? (posted 10/15/09)
Any charges applied to the deductible and out-of-pocket maximum during the year in which you turn 65 will be credited toward your deductible and out-of-pocket maximum under the Aetna Medicare Plan (PPO).
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Medical Mutual Plans
During the remainder of 2009, should a new retiree who is under age 65 enroll in an Aetna plan when Aetna will no longer be available after Jan. 1, 2010? (posted 10/15/09)
Aetna is no longer a plan option for 2010 for non-Medicare enrollees. Therefore, it may be in the best interest of non-Medicare enrollees not to enroll in Aetna for the remainder of 2009.
Why is STRS Ohio terminating the option of the Aetna plans for enrollees under age 65? (posted 10/15/09)
STRS Ohio conducted an extensive review process in conjunction with three other Ohio public pension plans. This process showed that Medical Mutual’s lower administrative fees and provider discounts could save $8.7 million each year for the STRS Ohio Health Care Program.
How can I determine if my provider is in the Medical Mutual network? (posted 10/15/09)
Enrollees may call Medical Mutual’s customer service number toll-free at 1-877-520-6727 or visit Medical Mutual’s Web site at www.medmutual.com to access its provider directory. On the Web site, go to “Find a Doctor” and click on “In Ohio” or “Other States” to access the most current directory online. STRS Ohio member service representatives should also be able to advise you and direct you to the appropriate network for each state.
What options do I have if my provider is not in the Medical Mutual network? (posted 10/15/09)
If enrollees provide the full name and address of their provider, STRS Ohio will forward that information to Medical Mutual. Medical Mutual’s Provider Relations Department will contact the provider. In addition, Medical Mutual is working to identify highly utilized Aetna providers for the purpose of developing a provider recruitment plan.
What can I expect from Medical Mutual as a new enrollee with a Jan. 1, 2010, effective date? (posted 10/15/09)
Medical Mutual will send current Aetna enrollees a “Welcome to Medical Mutual” letter in October. This letter will contain important Medical Mutual contact information. STRS Ohio will send open-enrollment packets in late October that list all available plan options. In November, Medical Mutual will send “Getting Started” materials that provide coverage details and programs available through the plan. Medical Mutual will send new ID cards in December. New enrollees will also receive prescription drug plan ID cards from Express Scripts in late December. Finally, STRS Ohio will send enrollees a Medical Plan Description in early 2010 that outlines hospital/medical and prescription drug coverage.
What happens if I am in active treatment with a non-network provider? (posted 10/15/09)
Medical Mutual is developing an outreach plan to target enrollees in active treatment. This plan may allow for a 90-day waiver for use of out-of-network providers.
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Prescription Drug Program (Express Scripts)
The majority of questions about STRS Ohio’s prescription drug program for enrollees in the Aetna, Medical Mutual and Paramount health care plans can be answered by reviewing the PDFs below. If you have questions that are not answered after reviewing these documents, contact Express Scripts toll-free at 1-866-685-2792 or visit www.express-scripts.com.
 2010 Prescription Drug Program
Low-Cost Generic Drug List for Home Delivery
2010 Voluntary Tablet-Splitting Program
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