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 Home  Health & Welfare Medical  

Medical - Frequently Asked Questions
 

General Questions

 

Preferred Provider Questions

 

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.

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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
Outpatient x-ray services (including MRI, CAT scan, mammogram, sonogram) Alaska Regional Hospital
Outpatient laboratory Alaska Regional Hospital
Outpatient surgery Alaska Regional Hospital
Emergency room (when possible) Alaska Regional Hospital
Sleep study tests Alaska Regional Hospital
Physical therapy services Chugach Physical Therapy
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,

  • you will save money because your out-of-pocket costs will be lower in most cases,
  • 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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