Medicare Advantage Plan Improvements
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Effective January 1, 2024, the Rochester Area School Health Consortium (RASHP I) will provide coverage through Aetna.
As a result, Medicare Advantage plans through Excellus, MVP, and Univera will no longer be available to Gates Chili CSD retirees, effective January 1, 2024. Please note, those enrolled in a Classic Blue Plan are not impacted by this change at this time.
The good news about this change in health insurance is that you will NOT need to complete a new enrollment form. To make the transition seamless for our retirees, you will be automatically enrolled in a plan that most closely aligns to your current benefits. Current Gates Chili members of the Excellus PPO plan will be assigned to Aetna Plan 3 and current Gates Chili members of the Excellus HMO plan will be assigned to Aetna Plan 5.
This change comes as the result of a comprehensive analysis and vetting process this past spring. The 19 districts and regional-level NYSUT leaders that make up RASHP I requested a proposal for Medicare Advantage plans from five local and national providers: Excellus, Aetna, Humana, United Healthcare, and MVP.
Although Aetna was not the least expensive offering, the group selected Aetna based on its outstanding scores in the areas of member/district customer service, plan offerings, implementation, and references from current insured groups. In addition to lower premiums for those who contribute, these Aetna plans also feature other benefit enhancements such as lower copays for primary care visits and nationwide portability.
The next steps in this transition include in-person and virtual meetings that you are encouraged to attend to learn more about Aetna and its benefits. General questions are encouraged at these meetings. Any specific questions regarding your personal coverage should be asked at the virtual meeting or directly to an Aetna Medicare Advantage Plan Liaison. Additionally, within the next few weeks, you will be receiving an informational packet from Aetna to review before these meetings.
Please review the dates, times and locations below and/or take a moment to review the frequently asked questions for information about Aetna.
For your Doctor
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This flyer is informational for your doctor. It reviews the following items.
- What does the provider need to know regarding your Aetna plan?
- What does Aetna pay?
- How to bill Aetna?
- How to submit claims
- Electronic claims submission
- Paper claims submission
- An example of an Aetna ID card.
Doctor Flyer
About the Plan
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Will the Medicare Advantage Plan enhancement affect the Major Medical Plan?
The enhancement to the Medicare Advantage Plan to Aetna will NOT affect your Major Medical Plan. The Major Medical Plan will continue through Excellus as it has in the past.
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What is a Medicare Advantage plan?
A Medicare Advantage plan is another way to provide Original Medicare Part A (hospital insurance) and Part B (medical insurance) benefits, and more. Medicare Advantage plans are offered through private insurance companies and are approved by the Centers for Medicare and Medicaid Services (CMS). Medicare Advantage is also known as Medicare Part C.
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What is the Aetna Medicare Advantage PPO plan?
The Aetna Medicare Advantage PPO plan is a type of Medicare Advantage plan. RASHP and Aetna® have teamed up to provide you with enhanced medical and prescription drug coverage all in one plan. The combined coverage is called the Aetna MedicareSM Plan (PPO), and it’s designed exclusively for RASHP retirees.
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Does the Aetna Medicare Advantage PPO plan offer prescription drug coverage?
Yes. You’ll get both medical and prescription drug coverage, all in one plan. Your prescription drug coverage will generally remain as it is today. You will not experience a gap in prescription drug coverage, also referred to as “donut hole” coverage, regardless of the cost of your prescription drugs.
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Why is the Aetna Medicare Advantage PPO plan being offered?
RASHP and Aetna® have teamed up to provide you with enhanced medical and prescription drug coverage all in one plan. We chose this plan because it offers a good balance of quality, value and affordability.
With over 35 years of Medicare experience, you’ll see why more than 2.9 million retirees trust Aetna to provide quality benefit coverage.* Rest assured, you can too.
Quality
Each year, the Centers for Medicare and Medicaid Services (CMS) rate Medicare Advantage plans based on:
- Member satisfaction
- How well the plan helps members stay healthy
- How well the plan helps members manage their conditions
The Aetna Medicare Advantage PPO plan is rated as 4.5 out of 5 stars.**
Value and affordability
Costs to provide health care can change annually. CMS helps Medicare Advantage plans with high star ratings offer more affordable benefits. Aetna also regularly reviews benefits and health care costs to offer you value, without sacrificing quality.
**Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next. Our overall Part C and Part D rating is <4.5> Stars.
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Is RASHP saving money by making this plan update?
Both you and RASHP may save money with this change. Converting to the Aetna Medicare Advantage PPO plan lowers both RASHP cost to provide these benefits and your cost to participate in the plan. The Aetna plan offers medical and prescription drug coverage a similar cost to what you pay today.
Network Access
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Can I keep seeing my doctors?
With the Aetna Medicare Advantage PPO plan, you have the freedom to see any licensed provider as long as they are eligible to receive Medicare payment and accepts your plan.
With over 1,000,000 network providers and 4,000 network hospitals, you can continue to see your favorite doctors and hospitals. But you won’t pay more to see an out-of-network provider.
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How do I find out if my provider accepts the Aetna Medicare Advantage PPO plan?
Just call Aetna at 1-833-771-9476 (TTY: 711), Monday–Friday, 8 AM–9 PM ET. They’ll contact your doctor and confirm for you, or help you find other nearby doctors or hospitals to meet your needs.
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Once the plan becomes effective, will I need to let my provider know that I have changed plans?
You’ll need to provide your new Aetna member ID card when you receive medical and prescription drug services. The new ID card will replace your current ID cards. Your new Aetna ID card will be the only ID card you will need to carry.
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Do I need a referral to see a specialist?
With the Aetna Medicare Advantage PPO plan, referrals are not required.
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Do I need a primary care doctor?
With the Aetna Medicare Advantage PPO plan, a primary care doctor is not required, but highly encouraged to help you manage your overall health.
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What is my coverage if I am traveling in the United States?
In the United States, you can see any doctor who is eligible to receive Medicare payment and is willing to accept your plan. The plan provides nationwide coverage, so your benefits are the same anywhere in the U.S. The plan also offers a nationwide network of pharmacies.
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What is my coverage if I am traveling internationally?
Aetna® will cover urgent and emergency care while you are traveling outside the United States.
You will likely need to pay for any costs up front and then submit paid receipts directly to Aetna for reimbursement. Aetna reimburses medical expenses at Medicare rates.
Prescription drugs are not covered outside of the United States and its territories.]
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Will I be able to use the same pharmacies I use today?
You can use any pharmacy in the Aetna network. The pharmacy network includes over 65,000 pharmacies nationwide, so your pharmacy is likely included.
Eligibility
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Are there eligibility and enrollment requirements for Medicare Advantage plans?
To qualify for a Medicare Advantage plan, you must:
- Be enrolled in Original Medicare Part A and Part B
- Have a Medicare Beneficiary Identifier (MBI)
- Have a physical street address located in the United States (P.O. boxes are not accepted)
You will be notified if this information is not currently on file with RASHP.
Additionally, you cannot be enrolled separately in another Medicare Advantage plan. If you are currently enrolled in another Medicare Advantage plan, that coverage will automatically end when you enroll in the Aetna Medicare Advantage PPO plan.
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I have a covered spouse or dependent under age 65 and they are Medicare eligible. Can they be on the Aetna Medicare Advantage PPO plan?
If you have a spouse or dependent who is under age 65 and is Medicare eligible, or is Medicare eligible due to a disability, please contact RASHP, to request that your spouse or dependent be included in the transfer to the new plan.
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What if I am not eligible for Medicare?
If you (or your covered spouse or dependent) are not eligible for Medicare, you will remain on your current plan until you become eligible for Medicare coverage.
Coverage and Cost
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Does this plan require prior authorization?
In some cases, your provider may need to get approval in advance from the Aetna Medical Management Department for certain types of services or tests, and some prescription drugs. This is called “prior authorization.” Your provider is responsible for obtaining prior authorization.
Medical services and items requiring prior authorization are listed in your Schedule of Cost Sharing (SOC). Prescription drugs requiring prior authorization will appear in the plan formulary. You’ll receive this document after enrollment.
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Will the medicine I’m currently taking be covered under this plan?
Covered medicines and drugs are listed in the plan formulary and supplemental drug lists.
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Do I have to enroll in a Medicare Part D plan?
Medicare Part D is prescription drug coverage. You do not need to do anything to enroll in Part D coverage if you are enrolled in Original Medicare Part A and Part B. Your Aetna Medicare Advantage PPO plan includes Part D. If you enroll in another Part D plan, your Aetna Medicare Advantage PPO plan will be cancelled.
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Will I pay a late enrollment penalty for Medicare Part D?
If you have been continuously enrolled under a health plan that provides creditable prescription drug coverage, you will not pay a late enrollment penalty. If you haven’t been continuously covered, you may pay a penalty.
