AlaskaCare Defined Contribution Retiree Plan FAQ

The below information is provided for informational purposes. In the event of a conflict between the below information and the AlaskaCare Plan Document, the plan document controls.

For answers to frequently asked questions concerning the Defined Benefit Retiree plan click here.

General

  1. Who is eligible to participate in this retiree health plan?
  2. Members of the Defined Contribution Retirement plan (Public Employees’ Retirement System Tier IV and Teachers’ Retirement System Tier III) and their eligible dependents can participate. To be eligible for medical coverage you must have:

    • 10 years of service and be Medicare age eligible, or
    • Be any age with 25 years of service for peace officers/firefighters or;
    • Be any age with 30 years of service for all others.
    • Must have worked the prior 12 months and retire directly from the system.
  3. How do I know if I am PERS Tier IV or TRS Tier III?
  4. Specific information on your individual tier status can be obtained through the Division of Retirement and Benefits Member Services Contact Center at or by calling (907) 465-4460 in Juneau or (800) 821-2251 toll-free Monday through Thursday from 8:30 a.m. to 4 p.m. or Friday from 8:30 a.m. to 3 p.m.

    In general, if you are a member of the Public Employees’ Retirement System (PERS) and first entered service after June 30, 2006, you are Tier IV. If you are a member of the Teachers’ Retirement System (TRS) and first entered the system after June 30, 2006, you are a Tier III.

  5. Who is considered an eligible dependent?
    • Your spouse. You may be legally separated but not divorced.
    • Your children from birth (exclusive of hospital nursery charges at birth and newborn care) up to 23 years of age only if they are:
      • your natural children, stepchildren, foster children placed through a State foster child program, legally adopted children, children in your physical custody and for whom bona fide adoption proceedings are underway, or children for whom you are legal, court-appointed guardian (if child is not your natural-born child);
      • unmarried and chiefly dependent upon you for support; AND
      • living with you in a normal parent-child relationship.
        • This provision is waived for natural/adopted children of the benefit recipient who are living with a divorced spouse, assuming all other criteria is met. Stepchildren must live with the retiree 50% or more of the time to be covered under this plan.
      • In addition, if they are between the ages of 19 and 23, they must be attending school regularly on a full-time basis.

    Children incapable of employment because of a mental or physical incapacity are covered even if they are past age 23. However, the incapacity must have existed before age 23 and the children must continue to be unmarried, rely chiefly on you for support and living with you in a normal parent-child relationship. You must furnish the claims administrator evidence of the incapacity, proof that the incapacity existed before age 19, and proof of financial dependency. Children are covered as long as the incapacity exists and they meet the definition of children, except for age. Periodic proof of the continued incapacity may be required.

  6. Why aren't dependents covered to age 26 under the Retiree health plan?
  7. The definition of retiree dependents limiting coverage to age 19 (or age 23 if a full-time student) comes directly from Alaska statute.

    Expanding dependent coverage to age 26 is one of the provisions in the Federal Patient Protection and Affordable Health Care Act (PPACA) and the Health Care and Education Reconciliation Act (HCERA) that became effective March 2010. This provision affects employee plans and retiree-only health plans differently.

    On June 14, 2010, the U.S. Departments of Health and Human Services, Labor, and Treasury issued regulations on Grandfathered Health Plans under PPACA. In the preamble to the Interim Final Rule, the Secretaries clarify that it is not their intent to apply the PPACA coverage to retiree-only health plans. This means DCR medical plan, is not subject to the expanded dependent coverage provisions of PPACA.

  8. Why have I received three ID cards?
  9. To improve our network and customer service, AlaskaCare selected Aetna to administer all medical, pharmacy, vision and audio claims, and Moda Health to administer all dental claims. You should have received a medical ID card, and if you elected the dental/vision/Audio plan you should have also received a vision/audio ID card from Aetna and a dental ID card from Moda to use when visiting your health care provider or pharmacy.

  10. I am newly retired and my ID card hasn't arrived, what should I do?
  11. Medical/Rx ID Card

    If your ID card hasn't arrived, you can view and print your Medical/Prescription ID card or download the mobile app that displays the ID card on your smartphone. Note: Aetna Navigator registration required.

    You can use your Social Security number to register or call the Aetna health concierge at (855) 784-8646 for assistance.

    Dental ID Card

    To print your Moda Health/Delta Dental of Alaska ID card or download the MyModa mobile app, register on the MyModa Web site or call Moda at (855) 718-1768.

  12. How do I install the iTriage app on my mobile device?
    1. Download or update the free iTriage App from your App store/Google Play Store.
    2. Create a "MyiTriage" account (found in the lower left of the standard app).
    3. Choose "My Insurance" and then select "Aetna" as your insurance carrier.
    4. Enter your Aetna Member ID and Group Number as they appear on your ID card. If entered correctly, Member ID and Group Number will be validated.
    5. Select "Link Aetna Navigator Account" and add your Aetna Navigator login and password.*

    *If you don't already have an Aetna Navigator account, you will be able to create one on this page.

Premiums

  1. How much will I need to pay to have major medical and pharmacy coverage?
  2. Employees do not contribute to the DCR health trust while they are actively working.

    When the employee retires, the DCR medical plan requires Medicare-eligible participants to pay a percentage of the monthly premium. Prior to Medicare eligibility, retirees pay 100 percent of the DCR medical plan cost. After Medicare eligibility, retirees pay a percentage of the plan cost based on years of service:

    Years of Service Retiree Contribution Percentage
    10-14 30%
    15-19 25%
    20-24 20%
    25-29 15%
    30+ 10%

    Please follow this link to find current premium rate information.

Recognized Charge

  1. What is recognized charge?
  2. A recognized charge is the maximum amount that AlaskaCare's Medical, Vision and Audio plans will pay for a covered service. The term recognized charge is sometimes referred to as the usual, customary and reasonable (UCR) charge or the maximum allowed charge. The recognized charge is determined differently for professional (provider) services, facility services, and pharmacy services.

    An out-of-network provider, facility, or pharmacy, has the right to bill you for the difference between the recognized charge and the actual charge. This is sometimes referred to as balance billing.

    When you use a network provider, facility, or pharmacy, you are not subject to balance billing for covered services. In other words, the provider, facility, or pharmacy, has agreed to accept, as payment in full, the recognized charge for the service provided. You are only responsible for payment of other applicable charges such as deductibles, co-insurance, and/or non-covered charges. This is an important financial consideration when choosing a provider, facility, or pharmacy.

    The facility recognized charge for services or supplies is the lesser of:

    • The amount the facility bills, or
    • The percentage of Medicare fee schedule that most closely reflects the aggregate contracted rate with the preferred hospital (currently 185% of Medicare).

    The pharmacy recognized charge for prescription drugs is the lesser of:

    • The amount the provider bills, or
    • 110% of the average wholesale price or other similar resource.

    The provider recognized charge for medical, vision, and audio services or supplies is the lesser of:

    • The amount the provider bills, or
    • The 90th percentile of the prevailing charge rate for the geographic area where the service is furnished. The 90th percentile of the prevailing charge rate means the charge that is at or below 90% for all of the charges reported for a service within a specific geographic area.

    For assistance with determining a specific recognized charge, call Aetna's Health Concierge at (855) 784-8646 or use the Consumer Cost Lookup tool at www.fairhealthconsumer.org.

    Please see the Dental FAQs for information on the dental recognized charge.

  3. How does Medicare impact the recognized charge?
  4. The recognized charge when Medicare is primary and you are receiving a Medicare covered service is assumed to be the Medicare allowed rate and will be determined by Medicare. If you are receiving services that are not covered by Medicare, the provider has the right to bill you for the difference between the recognized charge as determined by the AlaskaCare plan and the actual charge. If you receive services with a provider that has opted out of Medicare, neither Medicare nor the plan will pay benefits for their service.

  5. How is the provider recognized charge amount determined?
  6. The recognized charge for out-of-network providers is the 90th percentile of the prevailing charge rate for the geographic area where the service is furnished. The AlaskaCare plans establish the percentile (i.e., 90th percentile) to be applied to the prevailing charge rate; however, the prevailing charge rate is reported by FAIR Health, an independent not-for-profit corporation. FAIR Health collects charge data from claims received by insurance plans and health plan administrators across the country for charges billed by physicians, hospitals, and other healthcare providers. Charges reported are the full fees that healthcare professionals report to insurers as part of the claims process—not the negotiated rates that apply when visiting a network provider. Charges reported are maintained by FAIR Health in its database which is comprised of billions of claims for billed medical procedures from across the United States. New charge data are continually added to the FAIR Health database.

  7. How does FAIR Health validate their data?
  8. FAIR Health has audit and validation programs in place to ensure the integrity of its data. Part of the validation process entails testing the data with statistical algorithms and examination by FAIR Health's in-house statistical and technology experts. A team of healthcare researchers from leading academic institutions advise FAIR Health on the best methods for analyzing its national claims data. FAIR Health is also advised by an independent Scientific Advisory Board of prominent researchers who review Fair Health's statistical methods and data. FAIR Health also seeks input from other stakeholders such as consumer and patient advocacy groups, healthcare providers, actuaries and federal officials.

  9. How are services identified in the FAIR Health database?
  10. Each specific service, procedure or supply in the FAIR Health database has a unique Current Procedural Terminology (CPT) code. CPT codes are numbers assigned to medical services and procedures. CPT codes are part of a uniform system of coding maintained by the American Medical Association and are used by providers, facilities and insurers. Each CPT code is unique. There are currently over 10,000 medical services and procedures classified by CPT code. Most CPT codes are very specific. For example, the CPT code for a 15-minute office visit is different from the CPT code for a 30-minute office visit.

  11. How are the geographical areas determined?
  12. FAIR Health organizes its data by geozip— and a geographical area is usually defined by the first three digits of the U.S. zip codes. Geozips may include areas defined by one three-digit zip code or a group of three-digit zip codes. Geozips generally do not include zip codes in different states. The State of Alaska is currently defined by five geozips:

    • 995—including Anchorage, Bethel, etc.
    • 996—including Homer, Kodiak, etc.
    • 997—including Fairbanks, Kotzebue, etc.
    • 998—including Juneau, Sitka, etc.
    • 999—including Ketchikan, Prince of Wales, Wrangell, etc.

  13. What if there are not enough occurrences of a procedure in a particular geozip?
  14. When the volume of claims is insufficient to create a benchmark based on actual data, geozips 995 and 997 and geozips 996 and 998 will be combined. If the volume of claims is still insufficient, the benchmarks will be derived.

    If there are fewer than nine occurrences of a procedure in a geographic area, the plan uses FAIR Health's "derived charge data" instead. This data is based on the charges for comparable services, multiplied by a factor that takes into account the relative complexity of the service. If this information cannot be obtained locally, then national data is used.

  15. What factors can affect the recognized charge?
  16. The following factors can affect the recognized charge:

    • Billing errors: when a provider makes a mistake on either the procedure code or zip code.
    • Multiple procedures: when a provider performs multiple surgical procedures during a single session. The standard practice in such cases is to bill 100% for the primary (largest) procedure, 50% for the secondary procedure and 25% for all others. However, incidental items that require little or no additional time should not have an additional fee.
    • Unbundling: when a provider shows separate codes on the bill for related or incidental services. For example, instead of being billed separately, related blood tests performed at the same time should be billed under a single General Health Panel code.
  17. How can I make sure an out-of--network provider's rate will be within the recognized charge?
  18. You can verify whether an out-of-network provider's charges are within the recognized charge by calling the Aetna Concierge and providing the following information: (1) the procedure code, (2) the zip code where the service is to be performed, and (3) the projected cost. Aetna will use this information to estimate whether the proposed amount is within the recognized charge. Remember, if you use an Aetna network provider, those providers have already contracted with Aetna to offer discounted fees and those discounted fees are deemed to be within the recognized charge.

  19. What should I do if my out-of-network provider charges more than the recognized charge?
  20. If the out-of-network provider's claim exceeds the recognized charge, and you have already paid your out-of-network cost-sharing amount, wait for the provider to send you a bill, since the out-of-network provider may adjust their charges after reviewing the claim payment. If not, ask the out-of-network provider to:

    1. Consider reducing or waiving their fee to meet the recognized charge amount;
    2. Review the bill to ensure the correct procedure code and amount was used (and if not, submit a corrected bill to the plan);
    3. Confirm that the out-of-network provider charged their normal fee for the service, or if the out-of-network provider increased the charge due to unusual circumstances. If so, ask the out-of-network provider to either submit a corrected bill to the plan or provide a written explanation so you may file an appeal with the plan.
  21. What are Aetna's policies for claims reimbursement?
  22. Aetna's claim reimbursement policies address the appropriate billing of services, taking into account factors that are relevant to the cost of the service such as:

    • The duration and complexity of a service;
    • Whether multiple procedures are billed at the same time, but no additional overhead is required;
    • Whether an assistant surgeon is involved and necessary for the service;
    • Whether follow up care is included in the price of the service;
    • Whether there are any other characteristics that may modify or make a particular service unique; or
    • When a charge includes more than one claim line, whether any service described by a claim line is part of or incidental to the primary service provided.

    These claim reimbursement policies are based on:

    • Policies developed for Medicare;
    • Peer-reviewed, published medical journals;
    • Available studies on a particular topic;
    • Evidence-based consensus statements;
    • Expert opinions of health care professionals;
    • Guidelines from nationally recognized health care organizations.
  23. When I use an out-of-network provider, how much of the bill am I responsible for?
  24. If you or your dependent are not Medicare age eligible and use an out-of-network provider, you are responsible for the difference between the recognized charge and the amount charged by the provider in addition to other applicable charges such as deductibles, co-payments, co-insurance, any applicable penalties, and non-covered charges. If you or your dependent is Medicare age eligible, Medicare is the primary payer and AlaskaCare network considerations are not applied, so you should be sure to use a provider who accepts Medicare.

  25. How can I appeal a recognized charge determination for an out-of-network provider?
  26. You may appeal a recognized charge determination by providing additional information to indicate why the recognized charge was not correct, such as incorrect procedure codes, an incorrect zip code, etc. Information on appealing claim decisions is available in the AlaskaCare Retiree Benefit Plan for DCR Plan Retirees booklet.

  27. Where can I get more information about recognized charges?
  28. Specific plan language regarding recognized charges is available in the AlaskaCare Retiree Benefit Plan for DCR Plan Retirees.

  29. How do I avoid recognized charge issues?
  30. See a network provider if one is available. When you receive services from a network provider, the provider has agreed to accept the amount the plan will pay for services, and they may not bill the patient for any amount beyond that (excluding any cost sharing amounts such as deductible, the member’s coinsurance, and any other applicable copayments).

    To find out whether your doctor is a member of the Aetna network, call Aetna's Health Concierge at (855) 784-8646 or select the "Find a Doctor" button on our Web site at AlaskaCare.gov. To find out whether your dentist is a member of the Moda/Delta Dental network call Moda/Delta Dental at (855) 718-1768 or select the "Find a Dentist" button on our website.

Network

  1. I'm a retiree who is not yet Medicare age eligible; why should I use a network provider?
  2. Using network providers can provide substantial benefits to members and their dependent(s) who are not yet Medicare age eligible through the elimination of what's known as "balance billing." It can also generate substantial savings to members through negotiated provider discounts. To find out whether your doctor is a member of the Aetna network, call Aetna's Health Concierge at (855) 784-8646 or select the "Find a Doctor" button on our Web site at AlaskaCare.gov. To find out whether your dentist is a member of the Moda/Delta Dental network call Moda/Delta Dental at (855) 718-1768 or select the "Find a Dentist" button on our website.

  3. Are all services provided at the preferred hospital or facility considered services provided in network?
  4. Yes, as long as the service is provided (billed) by a preferred hospital or facility. However, you may find that not all providers at a preferred hospital or facility are part of the network. For example, if you have a surgical procedure performed at a preferred hospital, you may find that the hospital and surgeon are in the network, but the anesthesiologist is out-of-network. When you receive your bill, you'll see that it reflects the negotiated network rates for your hospital and surgeon. The anesthesiologist, however, may charge what s/he chooses since s/he has no negotiated network contract. If the anesthesiologist claim exceeds the recognized charge, you may receive a bill for the balance. It is wise to talk to your providers before incurring any expenses to see if they are covered in the network. You can also call the Aetna Concierge for additional information at (855) 784-8646 prior to receiving services.

  5. Will I be penalized if I use a preferred hosptial or facility, but the provider is out-of-network?
  6. No. The 20% coinsurance differential that applies to out-of-network facilities only applies to the facility services or supplies, and not to the professional services billed by the provider. Similarly, the increased annual out-of-pocket maximum, and out-of-network facility recognized charge calculation do not apply to the professional services billed by the provider.

  7. Will I face a penalty for using an out-of-network facility?
  8. If you receive care at an out-of-network hospital or other facility either in the Anchorage area or outside of Alaska, including surgery centers, birthing centers, rehabilitative centers, and residential treatment centers, you may be subject to higher out-of-pocket costs. These include a 20% reduction in the coinsurance that the plan pays; and an increase in the individual out-of-pocket maximum. Additionally, the maximum allowable rate for out-of-network facility charges is the lesser of what the facility bills or submits for that service or supply, or the percentage of Medicare that most closely reflects the aggregate contracted rate with the preferred hospital or facility (currently 185% of Medicare).

    To avoid incurring a penalty, be sure to use the preferred hospital or facility in your area. There may not be a preferred hospital or facility in some parts of Alaska, and in those instances, members will not incur a penalty. However, it is recommended you contact the Aetna Concierge for additional information at (855) 784-8646 prior to receiving services. You can also find a listing of network facilities by visiting our Find a Provider page.

  9. What if there is no network provider in my area?
  10. The DCR medical plan only penalizes use of out-of-network providers for the following services: hospital and facility services, preventive care, and limited circumstances such as transplants or inpatient mental health treatment. If you require these types of services, it is important to contact the Aetna concierge team. They can help you find a network provider or facility in your area, or discuss options with you. The DCR medical plan does provide travel coverage for treatment not provided locally or for surgery or diagnostic procedures that can be obtained more cheaply in another geographic region and members may explore these options with the Aetna Concierge team at (855) 784-8646 prior to receiving services.

  11. Is there a "network" for durable medical equipment (DME)?
  12. Aetna does have a DME national provider listing on their DocFind website. To see the current listing, go to AlaskaCare.gov and select the Find a Doctor tool. In DocFind type “durable medical equipment” in the "Search for:" box and enter the appropriate zip code and plan.

    The DME national provider list can be found at the top of the generated list, followed by local DME providers, if any. There is no penalty for using an out of network durable medical equipment provider; but you may save money by using a network provider and a non-network provider may bill you for charges above the allowable.

Medicare

  1. Am I required to enroll in Medicare Parts A and B?
  2. You are not required to enroll in Medicare Parts A and B, but the AlaskaCare Retiree Benefit Plan for DCR Plan Retirees will estimate the portion that Medicare would have covered before paying benefits regardless of your enrollment status. Therefore not enrolling in Medicare Part A & B as soon as you become age eligible may have very significant negative financial impacts for you. Members are strongly urged to consider enrolling in Medicare Part A & B three months prior to their 65th birthday.

  3. Do I have to pay a premium for Medicare?
  4. For many people, Medicare Part A is premium-free. However, if you are not eligible for premium-free Part A, you may need to pay a monthly premium. Everyone must pay a monthly premium for Medicare Part B. For additional information, visit Medicare.gov.

    For information on how you may be reimbursed for Medicare premiums from your Health Reimbursement Arrangement Account, see section 4, Health Reimbursement Arrangement (HRA) of the plan booklet.

  5. Do I need to get Medicare part D?
  6. Currently, you are not required to enroll in Medicare Part D as the drug coverage benefits you have through your AlaskaCare Retiree plan are at least as good as the required benefits offered under Medicare Part D. By not enrolling in Part D, you can avoid unnecessary premiums and coordination between Medicare and AlaskaCare for your prescription drugs. When the plan incorporates the Employer Group Waiver Program, this will change and you will receive additional instruction and communication in advance of this change.

  7. Do I need to get Medicare part C?
  8. You are not required, but may opt to take part in Medicare part C. Part C plans are Medicare Advantage plans provided by private insurers for members who live outside the State of Alaska. They cover the same services as Medicare Part A and B combined as well as some supplemental benefits. The AlaskaCare plan acts as a supplemental plan for Medicare eligible retirees, but you may elect to take part in Medicare part C in lieu of the AlaskaCare Retiree Benefit Plan for DCR Plan Retirees.

Vision

  1. What should I do if my provider tells me I don't have vision coverage but I know I do?
  2. Be sure to use your separate Aetna Vision/Audio ID card to prevent providers from receiving incorrect information when verifying your vision benefits through Aetna's self-service tool. If you believe your provider has incorrect information, you can call the Aetna Concierge at (855) 784-8646 to verify your vision benefits.

  3. How do I find a network vision provider?
  4. The AlaskaCare Retiree Vision Plan does not have a network. This means you may choose to see any provider and receive plan benefits for covered services.

  5. Is my provider required to submit my claims for me?
  6. No, you are responsible for submitting your vision claims to Aetna for processing. Your provider may be willing to file the claim for you, but it is the member's responsibility. View the Vision Benefits Claim form.

Dental

  1. Is there a dental network if I have Medicare?
  2. Yes, Medicare does not cover most dental services and you have access to the Moda/Delta Dental network of providers through your AlaskaCare coverage if you choose to select the optional dental plan. It is important to choose a dental provider that participates in the network to avoid the potential for unnecessary additional expenses and to fully enjoy the resources and savings available through the network.

  3. What is the dental plan recognized charge?
  4. The AlaskaCare Dental Plans limit payment of covered services to the recognized charge. An out-of-network provider has the right to bill you for the difference between the recognized charge and the actual charge. This is sometimes referred to as balance billing.

    When you use a Delta Dental network provider, you are not subject to balance billing for covered services. In other words, the provider has agreed to accept, as payment in full, the recognized charge for the service provided. You are only responsible for payment of applicable deductibles, co-insurance and/or non-covered charges.

    The recognized charge is the maximum amount the AlaskaCare Dental Plans will pay for a covered service.

    The recognized charge for each service or supply provided by a network provider in Alaska is the lesser of:

    • 100% of the covered expense;
    • 100% of the provider's accepted filed fee with Delta Dental; or
    • 100% of the provider's billed charge.

    The recognized charge for out-of-network providers in Alaska is the lesser of:

    • The provider's billed charge; or
    • 75% of the 80th percentile of the prevailing charge rate as determined by Delta Dental; except in the case of services rendered by an endodontist the recognized charge is 100% of the 80th percentile of the prevailing charge rate as determined by Delta Dental.

    The recognized charge for out-of-network providers outside Alaska is the lesser of:

    • The provider's billed charge; or
    • The prevailing charge rate as determined by Delta Dental.
  5. How is recognized charge determined in Alaska?
  6. Delta Dental of Alaska maintains a database of billed charges from its adjudicated claims in Alaska. The 80th percentile is calculated for every American Dental Association (ADA) procedure code using a statistically valid methodology, which removes outlier charges. This calculation is based on the most recent 12 months of processed claims and serves as the starting point for determining updates to the prevailing charges.

  7. How is the prevailing charge determined in Alaska?
  8. Delta Dental of Alaska incorporates a number of factors into the process they use to determine the 80th percentile. :

    1. The 80th percentile is determined statewide in order to maximize the statistical significance of the calculation.
    2. Additional data sources are compared to the results of the 80th percentile calculation for consistency purposes. Other data sources reviewed by Delta Dental are:
      • The Delta Dental Submitted Charges Database (DSC): This dataset is maintained by Delta Dental nationally and includes submitted charges from all Delta Plans for services rendered in Alaska.
      • The rates reported by Fair Health, an independent non-profit corporation.
      • Market research on prevailing charges used by other insurance carriers.
    3. For each procedure code, the current prevailing charge is compared to the 80th percentile calculation. Any changes to the current prevailing charge indicated by the 80th percentile calculation must be consistent with the other data sources referenced above. For new procedure codes, or those where there are too few procedures for a statistically valid 80th percentile calculation, additional considerations taken into account are:
      • The complexity of the service or supply;
      • The degree of skill needed; and
      • The cost of any materials required for the service.
    4. When a change in the prevailing charge is indicated, the change is limited to maximum percentage change unless otherwise indicated.

  9. Is this same 80th percentile calculation used for specialists?
  10. If the service provided by the specialist is exactly the same as that provided by the general dentist, the prevailing charge is the same for both (e.g. full mouth X-rays). However, if the services provided are specific to a specialist's training, the specialist will be reimbursed at a higher prevailing charge.

  11. How does the prevailing charge rate determination differ outside of Alaska?
  12. The prevailing charge is determined by a proprietary Delta Dental methodology for each individual state. If you are considering obtaining services from an out-of-network provider outside of Alaska, please contact Moda Health/Delta Dental at (888) 718-1768 for more details including determining if there may be network dental providers available to provide you with services you need and to obtain charge estimates for specific dental procedures to help you make an informed decision before you actually obtain the services and incur expenses.

Medical Necessity

  1. What is "medical necessity?"
  2. Medical necessity is one factor the AlaskaCare health plans consider in determining whether to provide coverage for a service or supply. The AlaskaCare health plans do not pay for services or supplies that are not medically necessary, such as cosmetic procedures.

    When Medicare or another plan is primary to the AlaskaCare Retiree Benefit Plan for DCR Plan Retirees, AlaskaCare will defer to the primary payers determination of medical necessity unless it is a service or supply that is specifically excluded under the plan.

    When the AlaskaCare medical plan is primary, the plan uses Aetna's current Medical and Pharmacy Clinical Policy Bulletins to determine medical necessity. The Aetna clinical policy bulletins are available to the public here.

    Determinations of medical necessity for dental procedures are made by Moda Health.

  3. How does Aetna determine if a service or supply is medically necessary?
  4. Aetna's clinical policy bulletins are based on:

    • Reports in published, peer-reviewed medical literature
    • Studies on a particular topic
    • Evidence-based consensus statements
    • Expert opinions of health care professionals
    • Guidelines published by nationally recognized health care organizations that include supporting scientific data

  5. Are there any limitations as to what kinds of services and supplies can be considered medically necessary?
  6. Under the AlaskaCare plans, services or supplies are never considered medically necessary if they:

    • Do not require the technical skills of health care professionals who are acting within the scope of their license
    • Are provided mainly for the personal comfort or convenience of you, your family, anyone who cares for you, a health care provider, or a health care facility
    • Are provided only because you are in the hospital on a day when you could safely and adequately be diagnosed or treated elsewhere, or
    • Are provided only because of where you are receiving the service or supply, if it can be provided in a doctor's or dentist's office or other less costly place.
  7. If a service or supply fits the definition of medical necessity, is it always covered by the plan?
  8. No, not all medically necessary services or supplies are covered by a health plan. For example, a medically necessary service or supply is not covered by the AlaskaCare plans when:

    • It is specifically excluded, or
    • The duration of the medically necessary service reaches a plan limitation (for example, some benefits are limited to a certain number of days, services, service per time period, expenses or visits).
  9. Shouldn't medical necessity be defined by the plan document, and not the Third-Party Administrator?
  10. The number of medically necessary procedures and unique circumstances of their application are virtually limitless, and as science progresses and the medical field changes, services that were once considered necessary may be recognized as unsafe or even harmful, or new services may be discovered that are more effective. The Third-Party Administrator (TPA) employs dozens, if not hundreds, of clinical experts who specialize in crafting medical necessity guidelines for multiple plans covering millions of lives across the United States. These guidelines are updated continuously to reflect changes and advances in research and technology.

    The Division of Retirement and Benefits has historically relied on the TPA to provide this service as it has never have the breadth of medical personnel, expertise, or experience to establish, maintain, and update clinical guidelines; and determinations of medical necessity are part of the claims processing function. Because AlaskaCare contracts with a TPA to perform this function, it is the TPA who makes determinations of medical necessity as part of the claims processing function.

    The clinical policy bulletins provided by Aetna set guidelines that are readily available on-line and transparent to members and their physicians, and clearly show the medical evidence relied upon to make the determination. The evidence basis of the policy bulletins are reviewed regularly and the bulletins are updated as necessary. Medical providers can also request peer-to-peer review with a TPA medical director to present additional medical evidence for consideration.

  11. If my doctor recommended the treatment, isn't that enough to support medical necessity?
  12. The National Institute of Health estimates that nearly 30% of all medical procedures or services performed in the United States are either unnecessary and provide no benefit to the patient, or even worse, are harmful. Additionally, a growing body of research indicates it can take as long as 17 years for medical evidence to move from research reccomendations to clincial practice. In a field driven by constantly evolving research and data, it can be difficult for providers to stay on top of the latest body of evidence for a particular procedure or episode of care. Aetna's clinical policy bulletins rely on carefully reviewed medical evidence to make decisions about coverage that are weighed against clinically accepted standards of medical practice.

    We encourage you to have your doctor review the clinical policy bulletins used to guide coverage decisions related to medical necessity. After your provider completes this review, and if they disagree, your provider may request a pre-determination of coverage and present additional medical evidence for consideration during the pre-determination review.

    To review your doctor's recommended treatment plan, and verify whether the services or supplies fit the definition of medical necessity, contact Moda Health at (855) 718-1768 for services covered under the dental plan, or contact the Aetna Concierge at (855) 784-8646 for services covered under the medical plan.

    If there continues to be a difference in opinion, you or your provider are encouraged to appeal the coverage decision.

  13. What can I do if a claim is denied because the third-party administrator determined my service is not medically necessary?
  14. If a claim is denied based on a medical necessity, you may request an explanation of the scientific or clinical judgment for the determination, free of charge.

    If you believe it's warranted, you may also initiate a written appeal to the plan. The AlaskaCare Retiree Benefits Plan for DCR Plan Retirees describe the process and timeline required for submitting an appeal.

    The appeals process used by AlaskaCare allows for the use of Independent Review Organizations (IRO) at level 2 of the appeals process. Use of an IRO allows for an impartial review by a third-party medical expert when there is disagreement regarding medical necessity.

Health Reimbursement

  1. What is a Health Reimbursement Arrangement?
  2. The Health Reimbursement Arrangement (HRA) is an IRS approved individual savings account, funded by employer contributions, used to reimburse eligible DCR participants tax-free for qualified out-of-pocket medical expenses and individual health insurance premiums.

    You or your dependent’s qualified medical expenses that are payable from your HRA include the following:

    • Amounts paid for health insurance premiums.
    • Copays, coinsurance, deductible, services, etc. not covered under AlaskaCare or another health plan.
    • Amounts paid for prescription medication, but not over-the-counter drugs unless prescribed by a licensed health care provider.

    You can find a general list of IRS-approved health-related reimbursements in Publication 502 online at IRS.gov.

  3. How do I know if I am eligible to access my HRA?
  4. To be eligible you must have retired directly from the DCR plan OR be eligible for Medicare and have a minimum of 10 years of service. For purposes of the HRA, to be considered retired directly from the plan, you must:

    • Have at least 30 years of service (other than peace officers and firefighters); or
    • Have at least 25 years of service if you are a peace officer or firefighter; or
    • Be a surviving spouse of a participant who had retired or who was eligible for retirement and medical benefits at the time of the participant’s death; or
    • Be an eligible dependent of a surviving spouse.

Coordination of Benefits (COB)

  1. What is Coordination of Benefits?
  2. Coordination of Benefits (COB) is a method of paying claims when you or your covered dependent have more than one health coverage plan. The AlaskaCare health plans coordinate benefits with other group health care plans to which you or your covered dependents belong. Coordination of benefits can be very confusing, even for people who work at a physician's office.

    With COB, if you are covered by more than one health care plan, the plans work together to provide benefits. One plan is considered "primary," and pays your covered expenses first. The other plan is "secondary," and depending on the plans COB provisions, may pay a portion or may pay any remaining covered expenses up to 100%. In some cases, there may be a third or fourth plan, as well.

    It is important to remember that not all expenses are covered expenses. In addition, each plan may have their own separate deductibles that may have to be satisfied independent of each other. The plans will likely also have independent and different copayments, coinsurance rates and annual out-of-pocket limits.

  3. How do you know who pays as primary, secondary, etc?
  4. Here are examples of common COB situations and rules:

    If You Are Covered Under… Here's How the Plans Pay
    Active employee plan and retiree plan Primary: Active employee
    plan Secondary: Retiree plan
    Retiree plan and as dependent under another person's plan through active employment Primary: Retiree plan
    Secondary: Other person's plan
    Retiree plan and Medicare-eligible Primary: Medicare
    Secondary: Retiree plan
    Two retiree plans Primary: Plan in force the longest
    Secondary: Other plan
    Retiree plan, as dependent under another person's plan through active employment, and Medicare-eligible Primary: Other person's plan
    Secondary: Medicare
    Third: Retiree plan
    Active employee plan, retiree plan, as dependent under another person's plan through active employment, and Medicare-eligible Primary: Active employee plan
    Secondary: Other person's plan
    Third: Medicare
    Fourth: Retiree plan

    If your dependent children are covered under more than one plan, in most cases, the plan of the parent whose birthday falls earlier in the year (not the oldest) is primary. If both parents have the same birthday, the plan that has covered the children longer is primary. If the parents are separated or divorced, the plans pay as follows:

    • Primary: plan of the parent whom the court has established as financially responsible for the child's health care (the claims administrator must be informed of the court decree)
    • Secondary: plan of the parent with custody of the child
    • Third: plan of the spouse of the parent with custody of the child
    • Fourth: plan of the parent who does not have custody of the child

  5. What if none of the COB rules above describe my situation?
  6. If none of the above rules applies, the plan that has covered the patient the longest is primary.

  7. How do the plans coordinate if my AlaskaCare Dental Vision Audio (DVA) plan is secondary?
  8. The AlaskaCare Retiree Dental, Vision, Audio (DVA) Plan for DCR Plan Retirees coordinates benefits differently than the medical plan does when it is secondary to another plan. For DVA services, the amount the plan pays after the deductible is met is figured by subtracting what the primary plan pays from 100% of expenses covered by the AlaskaCare plan on that claim.

    Example:

    • You obtain a filling from a network dentist who charges $200.
    • Both your dental plans pay 80% for class II (restorative) services.
    • You have met your deductibles for the year.
      • Primary plan pays: $160 (80% of $200)
      • Secondary plan pays: $40 (20% of $200)
      • Total paid: $200

    For medical services, when the AlaskaCare plan is secondary on a claim the plan will reduce the allowable amount by the amount paid by the primary plan, before applying the deductible, copays and/or coinsurance. The allowable amount is the total amount the AlaskaCare plan is responsible for, before any member cost share provision is applied.

    Example:

    • You are Medicare age eligible and obtain a service from a provider who accepts Medicare. The Medicare allowed rate for the service is $1,500.
    • Both Medicare and the AlaskaCare plan pay 80% for the covered service.
    • You have not met either your Medicare or AlaskaCare deductible for the year.
      • Medicare as primary plan pays: $1,067.20 ($1,500-$166 Medicare deductible = $1,334x80% is $1,067.20)
      • AlaskaCare DCR medical plan bases payment on: $432.80 ($1,500-$1,067.20)
      • AlaskaCare DCR medical plan pays as secondary: $106.24 ($432.80 - $300 deductible = $132.80x80% is $106.24)
      • Total paid by both plans: $1,173.44.
      • Unpaid portion ($326.56) applies to the annual individual out-of-pocket maximum.
  9. Will the coverage from two AlaskaCare plans always pay 100% of what the provider charges?
  10. No. Under the medical plan, the allowable amount on the second AlaskaCare plan will be reduced by the amount paid under the primary plan (see above example). You may also receive a balance bill for the amount over the recognized charge allowed under the primary plan if you receive services from an out-of-network provider. For more information on how recognized charges are calculated, see the Recognized Charges FAQs.

    Example:

    • You are not yet Medicare age eligible and obtain a service from an out-of-network provider who charges $500 for a procedure.
    • The recognized charge for the procedure is $425.
    • Both AlaskaCare plans pay 80% for the covered service.
    • You have met your annual deductibles.
      • The primary plan pays: $340 ($425x80% is $340)
      • The secondary plan bases payment on: $85 ($425-$340 paid by primary plan)
      • The plan pays as secondary: $68 ($85x80% is $68)
      • Total paid by both plans: $408.
      • Unpaid portion that you may be responsible for is $92. This is the difference between the billed amount and the allowable recognized charge ($75), plus your coinsurance ($17). Your coinsurance amount ($17) will apply towards the annual individual out-of-pocket maximum.

    You may also receive a balance bill if you use an out-of-network provider for dental services. In this case, the plan will pay up to the recognized charge for this service in your area. For more information on how recognized charges are calculated, see the Dental Recognized Charges FAQ.

    Example:

    • You obtain a filling from an out-of-network dentist who charges $250 for a filling.
    • The recognized charge for this service in Alaska is $150.
    • Both your plans pay 80% for class II (restorative) services.
    • You have met your deductibles for the year.
      • Primary plan pays: $120 (80% of $150)
      • Secondary plan pays: $30 (20% of $150)
      • Total paid: $150
      • Potential balance bill amount: $100 ($250 - $150)

    You may also receive a balance bill if one of your plans has a lower coinsurance rate (the percentage of the cost you pay for covered expenses once you meet any deductible) or excludes coverage for the service.

    Example:

    • You obtain a filling from a dental network provider who charges $200.
    • Your dental plan pays 80% for class II (restorative) services, but your spouse's plan only pays 10%.
    • You have met your deductibles for the year.
      • Primary plan pays: $160 (80% of $200)
      • Secondary plan pays: $20 (10% of $200)
      • Total paid: $180
      • Potential balance bill amount: $20 ($200 - $180)
  11. Are there other benefits to being covered by more than one plan?
  12. If you are covered under two AlaskaCare plans, the annual maximum that the plan pays will double. For example, under the Alaska care retiree dental plan, the annual $2,000 individual maximum would double to $4,000.

  13. Do frequency limits double?
  14. No, the maximum frequency of services per year is not increased due to having other coverage. For example, if you have two plans that each cover up to 20 spinal manipulations each year, the plan will coordinate payment on only 20 manipulations. Manipulations in excess of 20 would not be covered under either plan.

  15. How do the AlaskaCare plans coordinate with Medicare?
  16. If you are covered under AlaskaCare and age eligible for Medicare, your claims will be processed as if Medicare is your primary coverage regardless of whether or not you actually have Medicare coverage. This means that the AlaskaCare plan reduces the allowable amount it will pay by the amount that would have been paid under Medicare Parts A and B, regardless of whether you actually have Medicare. It's your responsibility to enroll in Medicare Parts A and B as soon as you become eligible and to pay applicable Medicare premiums.

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