Go 1199C and… Maximize Your Benefits
The POS Plan provides comprehensive coverage for wellness and preventative care, hospital and doctor’s charges, mental health/substance abuse treatment, and certain vision expenses.
The Medical Plan is designed to give you the freedom to receive care from the doctors and hospitals you choose. But the plan is also designed to encourage you to use facilities and doctors that keep our members employed.
Here’s how the plan works. We offer three levels of benefits.
LEVEL 1: Go 1199c and you’ll pay the lowest out-of pocket costs!
- Referred Care to 1199C Facilities/Providers—You receive maximum benefits when you use 1199C hospitals and 1199C- related providers. The plan pays 100% of most eligible expenses (you pay a copay for doctors’ office visits and certain other services). The Benefit Fund reimburses you for inpatient hospital copays ($250) and outpatient surgery copays ($100) so that you get virtually 100% coverage! Your out-of-pocket costs are lowest when you “Go 1199C.”
This benefit level only applies if your PCP or PCP-referred specialist admits you to a facility that employs 1199C members or gives you a referral to 1199C-related providers, such as Skilled Nursing Facilities, Home Health Care or outpatient mental health providers.
LEVEL 2: If your PCP refers you to a Facility that does not employ 1199C members or non-1199C related Provider you’ll pay much more out of your own pocket!
- Referred Care to Aetna QPOS Providers—The second benefit level applies if your Aetna PCP or PCP-referred specialist admits you to an Aetna participating facility that does not employ 1199C members or you are referred to non-1199C-related providers. This can result in significant out-of-pocket costs to you. The plan pays100% of most eligible expenses after you pay a $1,000 copay for inpatient admissions, a $500 copay for outpatient surgery, and a copay for certain other services such as doctors’ office visits, home health care, or skilled nursing facility care.
LEVEL 3: The most expensive way to receive care. I f you do not receive care from your PCP, or you receive care without a referral from you PCP, you will pay the most out of your own pocket.
- Self-Referred Care—This means you do not receive care from your Aetna PCP or you receive care without a referral from your PCP—even if you use providers that are in the Aetna QPOS network. When you choose this way to receive care, your out-of-pocket costs are highest because you pay a $500 deductible ($1,500 per family), 30% of the cost of most eligible expenses, plus a $1,000 copay for inpatient admissions ($500 for outpatient surgery). In addition, the Plan’s payment is based on the “maximum allowance.” Providers who are not in the Aetna network (“non-preferred”) may charge more than this maximum allowance, and you will be billed for the difference.
