Voiceover (Could be voice of Adrian):
The NYC Community Plan has been designed to help make health care benefits more affordable, accessible and desirable to New York City's diverse communities. Some of the special features this new health benefits plan offers you are:
No copays for preventive care services, thus removing financial barriers that prevent some members from utilizing these important benefits.
A network of community providers who better understand cultural preferences, needs and prevalent health conditions in the community.
Industry-leading tools, so that members and employers can easily and accurately manage their health care needs.
Adrian on screen: Hi, my name is Adrian and I'm an Account Executive from Aetna. I'm excited about presenting this new plan that we feel will meet you and your family's health care needs.
I'd like to start by giving you an overview of this new plan and then going over some common questions.
First let me tell you just exactly what this "NYC Community Plan" is. Here are some of the specifics.
This plan is offered specifically to employees that work and/or live and access health care in the five boroughs of New York City.
A new Aetna provider network has been specifically developed just for this plan consisting of both referred and self-referred providers throughout the NYC community.
There are two in-network levels of benefits, with no out-of-network benefits: Referred and Self-Referred benefit options. You, the member, have a choice.
1. Someone questioning (floating across screen): How do we find providers that are part of the referred and self-referred network?
Adrian: There are a couple of options available. The enrollment packet that you as an employee receive will include a provider directory created specifically for the NYC Community Plan. This provider directory is broken into two sections. The first section includes a listing of the referred providers and the second section includes a listing of the self-referred providers.
The pages are clearly marked with a header and footer.
The second option is through DocFind, an online search facility available though Aetna Navigator®. As an Aetna member, you can register on Aetna Navigator (provide URL) and access the DocFind link. Following the easy instructions you can access the most up to date listing of the NYC Community Referred and Self-Referred Network providers. The referred providers are uniquely identified within DocFind and are listed first.
2. Someone questioning: What do you mean by two in-network benefits?
Adrian: Let me show you.
Referred Benefit Level:
Services are available through the NYC Community Referred Network of providers and all are located within the 5 boroughs of NYC.
PCP selection is required (NYC Community Referred Network PCP will be auto assigned if one is not selected).
PCP referrals are required to access services to other NYC Community Referred Network providers. Services are not covered if a referral is not obtained.
Preventive services are covered at 100% with no copay.
Member out of pocket costs are limited to only a copay.
No Lifetime maximums apply.
Self-Referred Benefit Level:
Services are available through the NYC Community Self-Referred Network providers, (includes providers outside of New York City).
PCP referrals are not required.
Out-of-Pocket maximums and Lifetime maximums apply.
Well child visits and immunizations are covered at 100%, not subject to deductible and coinsurance.
Member's cost share for all other services are subject to deductible and coinsurance. (Adult preventive, specialist, etc.)
Self referral to non participating providers is not covered.
3. Someone questioning: Why should I select the referred level of benefits?
Adrian: Let me explain why you would want to choose this benefit level:
There is no cost for preventive services, which removes the financial barrier in accessing these important services, resulting in improved treatment outcomes.
Cost sharing for the referred level of benefits is limited to a copay, no deductible and coinsurance.
PCP's, who are the first point of contact, help members and their families achieve optimal health by providing continuity of care.
PCP's will have a better medical picture of their patients helping them identify medical changes or problems earlier.
NYC Community Referred Network providers better understand the cultural needs and concerns of members within their own communities.
4. Someone questioning: I work crazy hours, have two kids and sometimes find myself having to use the emergency room for urgent medical care. Would these services be covered?
Adrian: First let me mention that many of the NYC Community Referred Network providers have after-hour and weekend care options. This helps to meet some of the work schedules of many people like you.
Otherwise:
True emergencies are covered with a copay at any hospital emergency room.
Urgent Care Centers / Specialists require a copay when properly referred by your PCP.
Urgent Care Centers / Specialists are subject to a deductible and coinsurance when self referring to a self-referred network participating provider.
5. Someone questioning: To ensure I clearly understand this plan, if I want to go to Dr. Smith, but he is not an NYC Community Referred Network doctor, how would that work?
Adrian: This is a super question because you need to understand how this plan is unique.
The following will apply based on the participation status of the servicing provider. If Dr. Smith is a NYC Community Referred Network participating provider, a referral from your Primary Care Physician (PCP) is required. In this case the member out of pocket costs are limited to a co-payment. If you do not obtain a referral, the service will not be covered.
If Dr. Smith is a NYC Community Self-Referred Network participating provider, you can self-refer, (no PCP referral is needed), and the services will be subject to a deductible and coinsurance. If Dr. Smith is not participating in the NYC Community Self-Referred Network, services will not be covered. As you can see, it's more cost effective for you to see providers participating in the NYC Community Referred Network.
6. Someone questioning: My wife is going to have triplets in December. How would the hospital be paid and what do we need to do to make sure that this is covered correctly?
Adrian: Congratulations!
This would be considered a Transition of Care (TOC) event and standard guidelines apply to the NYC Community Plan. If approved then services would be covered under your referred level of benefits. So, only the applicable plan copays would apply. A TOC request form can be obtained after you enroll by calling the Customer Service number that will be listed on the member ID Card.
7. Someone Questioning: Can you explain how pharmacy drug coverage works?
Adrian: Sure. There are two options and your employer decides with their plan selection which option will be available to you. There's a prescription drug rider option which will display with an RX indicator on your ID card and the other is a discounted prescription drug option which is not indicated on your ID card.
The standard pharmacy option provides coverage for your prescription drugs.
The discount pharmacy option allows you to purchase prescription drugs at the Aetna discount rate versus full retail prices.
With either option, you simply present your member ID card to the pharmacy. They will verify coverage and charge the appropriate amount.
8. Someone Questioning: Do you have a sample ID card that you can show us?
Adrian: Of course! Take a look!
Notice that the Member/Provider Services contact numbers for Aetna are located at the bottom along with PCP and Specialist copay information.
Voiceover (Could be voice of Adrian): Should you ever have any questions other than the ones we've just gone over, please do not hesitate to call the Customer Service contact number located on that member ID card.
At Aetna, we are excited about the NYC Community Plan and the way that it addresses the diverse needs of small business employees in New York City. Thank you for putting your trust in Aetna and we are looking forward to serving you and your family's needs for a long time to come!
Health benefits and health insurance plans are underwritten by Aetna Health Inc. and Aetna Health Insurance Company of New York.
This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits vary by location. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Health benefits and health insurance plans contain exclusions and limitations. Discount programs provide access to discounted prices and are NOT insured benefits. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna's Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions.
Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. If you are in a plan that requires the selection of a primary care physician and your primary care physician is part of an integrated delivery system or physician group, your primary care physician will generally refer you to specialists and hospitals that are affiliated with the delivery system or physician group. Information subject to change.
