AlaskaCare Health Plans TPA Transition Guide
Our Mission: To provide high-quality, sustainable benefits for our members.
How we do it:
- Increase member engagement
- Promote evidence-based medicine
- Collaborate with providers
- AlaskaCare welcomes new partners
- How do I find out if my provider is in the new network?
- Five important items deserving your attention
- Additional information about changes to your plan
- Apps and Web sites
- Prescription drug plan information
- Aetna specialty pharmacy
- Precertification requirement changes
AlaskaCare welcomes new partners
The New Year will bring changes to both the retiree and employee AlaskaCare health plans, including a transition to new partners. Beginning January 1, 2014, Aetna will be administering all medical and pharmacy claims for the AlaskaCare Health Plans, and Moda Health/Delta Dental of Alaska will be administering all dental claims.
Members will receive two new ID cards before this date: one for medical and pharmacy benefits with Aetna, and one for dental benefits with Moda Health/Delta Dental of Alaska.
Through Aetna, AlaskaCare members will have a Health Concierge—a single-point-of-contact for all medical and pharmacy issues as well as claim and benefit questions. Aetna will also administer the COBRA, direct bill, HFSA, and dependent care programs.
If you have any questions, just call Aetna's Health Concierge at (855) 784-8646.
How do I find out if my provider is in the new network?
To find a medical, pharmacy or vision provider:
- You can call Aetna's Health Concierge at (855) 784-8646 to find out if your doctor is a network provider.
- You can also select the "Find a doctor" button in the left column of this Web site.
To find a dentist:
- If you have not received your ID card, you can call Moda Health/Delta Dental of Alaska at (855) 718-1768 to find out if your dental provider is a network provider.
- Once you receive your new ID card, you can access myModa by selecting "Dental Benefits" in the right-column of this Web site. Be sure to have your member ID handy the first time you log in.
Five important items deserving your attention
- Provider networks are changing – check to see whether your health care provider is in the new network by calling Aetna's Health Concierge at (855) 784-8646. You can verify your dental provider's network status by calling Moda Health/Delta Dental of Alaska at (855) 718-1768. Using network providers saves money and helps ensure the application of evidence-based-medicine principles.
- In keeping with national standards for improving quality of care and reducing unnecessary medical procedures, the precertification list for both health plans is expanding January 1, 2014. Beginning February 1, 2014, lack of precertification for specific out-of-network services and procedures will incur a $400 member penalty. Please review the precertification requirement list to ensure you don't get caught unprepared! If you have scheduled procedures with out-of-network providers that will require precertification between January 1 and 15, 2014, it is especially important that you review this information and contact Aetna in advance of the procedure, on or after December 20. For any procedures scheduled January 16 or later, please contact Aetna after January 1.
- For members currently enrolled in special care programs and members taking advantage of mail order and specialty pharmacy options:
- If you are in currently in a care program (case management, disease management, wellness coaching), a representative will contact you to discuss your care needs.
- If you currently receive mail order prescriptions, you will need to activate your mail order pharmacy services through Aetna Navigator on or after January 1, 2014.
- Compound prescriptions will no longer be offered through the mail order service. Contact Aetna's Health Concierge at (855) 784-8646 for more information.
- If you are receiving medications through the Envision specialty pharmacy, an Aetna representative will contact you after January 1.
- If you are receiving durable medical equipment or other supplies currently covered under the health plan through automatic shipments, please be sure the provider has updated insurance information.
- Both the employee and retiree plans will adopt Moda Health/Delta Dental of Alaska's standard dental plan language, which will include new frequencies and limitations for some procedures while offering improved coverage for other services. Read more information about the new dental network and updated coverage.
- Aetna's subsidiary, Payflex, will administer direct bill, COBRA, health flexible spending, and dependent care accounts. If you use automatic payment features to remit direct bill or COBRA amounts, you will need to change the destination bank account. Manually submitted HFSA and dependent care claims will also use a new process. Call (855) 784-8646 for assistance.
- Plan changes
- Promoting evidence-based medicine
- Expanded precertification requirements
- New dental network and updated coverage
- Streamlined access to mental health and chemical dependency benefit
- Compassionate care for end of life services
- Simplified appeals process
- Chiropractic treatment
On January 1, 2014, new plan provisions will become effective in both the active and retiree health plans. It is important that you familiarize yourself with them. These plan provisions reflect our values and objectives as we work to keep pace with the ever-changing medical market while providing high-quality, sustainable health care benefits. The health plan documents for both the employee and retiree health plans are being updated to reflect these plan changes and when complete will be available on this Web site and in print if requested.
Promoting evidence-based medicine
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. In order to help our members navigate a complex system and ensure they are receiving the best care possible, we are focusing on promoting evidence-based medicine in our plan designs. The plan changes below reflect our commitment to this objective.
Expanded precertification requirements
Precertification is a nationally accepted tool used to help avoid unnecessary procedures and support evidence-based medicine. Beginning January 1, 2014, expanded precertification requirements will take effect. For members receiving services from a network provider, the provider is responsible for precertification. If you receive services from out-of--network provider, then you become responsible for obtaining the precertification. If the precertification is not obtained, in many cases a $400 penalty will apply to covered expenses. Review the list of precertification procedures and don't get caught unprepared! The full listing of precertification requirements will be published in the updated plan booklets.
New dental network and updated coverage
AlaskaCare members will get to benefit from a dental network for the first time! Our new dental provider, Moda Health/Delta Dental of Alaska, brings decades of experience in managing dental plans along with extensive oral health expertise. Moda Health/Delta Dental of Alaska provides a network with over 300 licensed dentists throughout Alaska and 24,000 dental providers around the country. Network dentists offer significant discounts and do not balance bill. Be sure you are using a network provider to get the most out of your plan benefits by calling Moda Health/Delta Dental of Alaska at (855) 718-1768 for more information. The AlaskaCare Employee Health plan and the AlaskaCare Retiree Dental/Vision/Audio plans will be adopting Moda Health/Delta Dental of Alaska's standard plan language in place of the existing coverage. This means the plans will have frequencies and limitations that reflect proven standards of care.
It also means some services will be reclassified into new categories and extended benefits will be available to individuals with certain medical conditions, offering improved benefits. Please take a moment to review the new plan language when the updated booklets are published. If you have questions, please contact Moda Health/Delta Dental of Alaska at (855) 718-1768.
Streamlined access to mental health and chemical dependency benefits
When you need help, it should be easy. We are streamlining the process to receive outpatient treatment from a mental health or chemical dependency provider. Effective January 1, 2014, a referral will no longer be required for most outpatient treatment of mental health or chemical dependency visits.
Compassionate care for end of life services
Hospice benefits are now available to members in both health plans beginning January 1, 2014. These services will be covered as normal benefits and are subject to precertification.
Simplified appeals process
The appeals process in both health plans will be simplified beginning January 1, 2014.
- Level 1 Appeal: Aetna
- Level 2 Appeal:
- Coverage issues: Aetna
- Clinical issues: External Review Organization
- Level 3 Appeal:
- Employee Plan members: Superior Court
- Retiree Plan members: Office of Administrative Hearings
The existing $750 annual employee plan maximum for spinal manipulation services will be replaced by a 20-visit annual limit for spinal manipulation treatment.
Apps and Web sites
New tools are available to help support your health care decisions. From finding a network doctor to knowing your costs in advance, we have Web sites and apps to support your health care needs.
Aetna Navigator is a one-stop-shop for everything related to your medical benefits. You can access Aetna Navigator before January 1 either by using your Social Security number or, after you receive your new health care card, with your member ID. By logging onto this Web site you can:
- Find a provider*
- Estimate the cost of a procedure†
- View your claims history*
- Print your member ID card*
- Chat with a live Aetna representative
- Find decision support tools and educational materials
* These links are available in the right column of this Web site.
† This link is available as the "Know Your Cost" button in the left column of this Web site.
Instructions for first-time Navigator users
- After arriving at the Aetna login screen, click or tap "Sign Up Now"
- Enter your Member ID Number (if you have your card) or follow the link, "Social Security number"
- Follow directions, then click or tap "Continue" to register
Beginning January 1, you can also use Aetna Navigator to access PayFlex and check your health flexible spending or dependent care assistance accounts.
Aetna mobile app
If you have a mobile phone or tablet, once you are registered with Aetna Navigator you can download the Aetna app and log in so you can access your health care ID straight from your phone!
Need to find a provider on the go? How about view your claims status or download your ID card? As a Moda Health/Delta Dental of Alaska member, you get access to your own personalized Web site, myModa, where you can view benefit information, find a network provider, download your ID card, and more. Once you receive your dental care card, accessing myModa is easy—just select "Dental Benefits" in the right column of this Web site. From there, you can create an account or log in with your member ID to enjoy a wide range of additional benefits. You can also call Moda Health/Delta Dental of Alaska at (855) 718-1768 for help signing in.
We're pleased to offer you a digital ID card app. With your digital ID card app, your subscriber ID card is always with you and you can email your ID card to your dentist or family members. Smartphone users can download the ID card app from your app store. To search for your app, visit your app store and type "Moda Health eCard app" into your search. To launch the app, enter your mobile PIN code and member ID (found on your card) and your ID card will appear on your phone.
The following Web sites and apps will become available January 1, 2014.
The customized application is currently under construction. Please wait until February 1, 2014 to ensure you get the AlaskaCare version of iTriage.
Feeling sick? Need a provider? iTriage is a free mobile application that allows members to find a network provider, look up symptoms, learn about prescription medications, and lots more. After registering online with Aetna Navigator, download iTriage from your app store and log in with your member ID to see AlaskaCare's customized version.
AlaskaCare employee plan members have access to ActiveHealth's Web site to support their wellness and health care goals. To access these tools, tap or click the "Wellness" button in the left column of this Web site. On the Wellness page you will find the link to ActiveHealth.
24-Hour Nurse Information Line
Need medical advice? It's available to AlaskaCare members around the clock with the 24-hour nurse information line. Just call (800) 556-1555 or select "24-Hour Nurse Line" from the right column of this Web site.
Employee Assistance Plan
AlaskaCare employee assistance benefits have expanded with our new partners. In addition to more traditional EAP services, the plan now offers financial advice and legal assistance. Select "Employee" from the horizontal menu near the top of this Web site, then "Information," then "Employee Assistance Plan."
HealthSmart claims after January 1, 2014
HealthSmart will continue to process claims for services received through December 31, 2013. This means that you may still receive communications from them in 2014 as it can take several weeks for claims to process. If necessary, you can continue to contact HealthSmart using their number provided on your ID card after January 1, 2014 for claims incurred in 2013. You will also be able to go online to HealthSmart's Web site to look up your Explanation of Benefits (EOBs).
Things you should know about AlaskaCare's prescription drug plan partner
- New online tools
- Additional changes
- What will happen to my current prescriptions?
- Important prescription deadlines
- Aetna speciality pharmacy
Effective January 1, 2014, Aetna will become the administrator of your AlaskaCare prescription drug plan. Our goal is to provide high-quality, sustainable health care benefits and to support you in reaching your health care goals. We want to make this transition as easy as possible, so most of your existing prescriptions will automatically transfer to Aetna. With a few exceptions, you will still be able to get your prescriptions just like you always have.
New online tools are available
- Estimate prescription costs online so you can shop around and compare prices.
- Find a pharmacy near you and access your ID card on your mobile phone.
- Access Aetna Navigator's Rx tool to get more information about your prescriptions and medication interactions.
- Track your flexible spending account reimbursements easily through the Aetna Navigator Web site. First-time Navigator user instructions…
Additional changes of which to be aware
- Some medications may be filled differently, changing your out-of-pocket costs.
- The specialty pharmacy medication list has changed.
- Some drugs will require precertification before they are covered.
For additional information about your prescription drug coverage, the specialty drug program and precertification requirements, call Aetna's Health Concierge at (855) 784-8646.
What will happen to my current prescriptions?
- Prescriptions received through your local pharmacy do not need to be transferred. However, you will want to confirm that the pharmacy you use is in Aetna's network. When you pick up your first prescription on or after January 1, 2014, please make sure to present your new ID card to the pharmacy to assure smooth processing of your claim.
- Mail Order
- If you currently receive medications through the Envision mail order drug program, your open Envision mail order prescriptions will automatically transfer to the Aetna Rx Home Delivery® mail order pharmacy. However, you must contact the Aetna mail order pharmacy to confirm your refills for mailing. Beginning January 1, 2014, you can do this:
- Online – Access Aetna Navigator. Once in Navigator, click "Aetna Pharmacy" from the top of the page, and navigate to "Refill by Mail."
- Phone – Call toll-free at (888) 792-3862.
- Aetna Rx Home Delivery does not dispense compound medications. If you have a need for a covered compound medication and do not have a retail pharmacy that will prepare it, call Aetna's Health Concierge at (855) 784-8646 for information about your options.
- IMPORTANT: Mail order prescriptions for bulk compounds and restricted drugs such as opiates cannot automatically transfer and you will need to get a new prescription from your doctor.
- Specialty Drug Program
- If you already take advantage of the Envision specialty drug program, your open prescriptions for qualified specialty medicines will automatically transfer to the Aetna Specialty Pharmacy®. Current program participants should expect the Aetna Specialty Pharmacy to contact you to discuss the transition.
Important prescription deadlines
Please keep these dates in mind:
- December 31, 2013 – The last day to place orders through Envision mail order pharmacy.
- January 1, 2014 – Eligible open prescriptions on file with the Envision mail order or specialty pharmacies will transfer to Aetna Rx Home Delivery or Aetna Specialty Pharmacy.
Note: Expired mail order prescriptions or those written for controlled substances cannot be transferred. You must submit a new prescription along with an order form. Call Aetna's Health Concierge at (855) 784-8646 if you need assistance.
- After January 1, 2014 – Depending on the type of drug(s) you need, begin placing your orders with Aetna Rx Home Delivery or Aetna Specialty Pharmacy. It's easy to get started.
Save money by using the Aetna Specialty Pharmacy®
Do you take specialty medicine? You may use it to treat conditions like multiple sclerosis, rheumatoid arthritis or cancer. It may be injected, infused or taken by mouth. It often needs special storage and handling. Plus, a nurse or pharmacist should monitor you during your treatment.
Aetna Specialty Pharmacy offers all this and more and can result in significant savings. If you are not participating in this program today, please take a moment to learn about the substantial benefits you could be receiving. Shipping is free and your medicine arrives in private, secure packaging. Use this pharmacy to:
- Receive a standard 30-day supply of your medicine and more frequent follow up. This helps you to save money if your medicine or dose changes between refills.
- Save time—get your medication right where you want it! Have your medicine sent to your home, doctor's office, or anywhere you choose.
- Access pharmacists who can answer questions any time and check all prescriptions for accuracy.
- Find tips and training on how to inject your medicine, if needed, and support for coping with side effects.
As of January 1, 2014, take one of these steps to use the Aetna Specialty Pharmacy:
- Fax – Your doctor may fax your prescription to (866) FAX-ASRX (329-2779).
Mail – You or your doctor may mail your prescription order to:
- Aetna Specialty Pharmacy
- 503 Sunport Lane
- Orlando, FL 32809
- Phone – Your doctor may also call and speak to one of our registered pharmacists at (866) 782-ASRX (2779) during our normal business hours of 4 a.m. to 3 p.m. Alaska Standard Time.
Precertification requirement changes
Beginning January 1, 2014, expanded precertification requirements will take effect. Certain services, such as inpatient stays, certain tests, procedures and outpatient surgery require precertification by Aetna. Precertification is a process that helps you and your physician determine whether the services being recommended are covered expenses under the plan. It also allows Aetna to help your provider coordinate your transition from an inpatient setting to an outpatient setting (called discharge planning), and to register you for specialized programs or case management when appropriate. This commonly used medical management tool helps ensure you are receiving the most appropriate and effective care and supports our goal to promote evidence-based medicine.
What you need to know:
- For members receiving services from a network provider, the provider is responsible for precertification.
- If you receive services from a non-network provider, then you become responsible for obtaining the precertification. If the precertification is not obtained, in many cases a $400 penalty will apply to covered expenses.
- If you are planning to receive any of the services listed below between January 1, 2014 and January 15, 2014, you or you provider can call Aetna's Health Concierge at (855) 784-8646 beginning Friday, December 20 to receive precertification in advance. For procedures scheduled January 16 or later, please contact Aetna's Health Concierge after January 1.
Precertification is required for the following types of medical expenses:
- Stays in a hospital
- Stays in a skilled nursing facility
- Stays in a rehabilitation facility
- Stays in a hospice facility
- Outpatient hospice care
- Stays in a residential treatment facility for treatment of mental disorders and substance abuse
- Partial hospitalization programs for treatment of mental disorders and substance abuse
- Home health care
- Private duty nursing care
- Transportation (non-emergent) by fixed wing aircraft (plane)
- Elective (non-emergent) transportation by ground
- Autologous chondrocyte implantation, Carticel (injection into the knee of cartilage cells grown from tissue culture)
- Cochlear device or implantation (surgical implant of a device into the ear to try to improve hearing)
- Cognitive skills development (treatment to improve thinking skills)
- Non-orthodontic customized braces
- Dental implants and oral appliances
- Dialysis visits
- Dorsal column (lumbar) neurostimulators: trial or implantation (electrical stimulation of the spinal column to try and relieve intractable pain)
- Electric or motorized wheelchairs and scooters
- Gastrointestinal tract imaging through capsule endoscopy
- Hyperbaric oxygen therapy
- Limb prosthetics
- Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint (reconstructive surgeries to attempt to correct structural abnormalities of the jaw bones)
- Osseointegrated implant
- Osteochondral allograft/knee (grafting of cartilage and bone from a cadaver to the knee joint)
- Proton beam radiotherapy
- Reconstruction or other procedures that may be considered cosmetic
- Surgical spinal procedures
- Uvulopalatopharyngoplasty, including laser-assisted procedures (surgery to reconfigure the soft palate to try to help with sleep apnea)
- Ventricular assist devices
- Organ transplants
- Intensive outpatient programs for mental disorders and substance abuse:
- Amytal interview
- Electroconvulsive therapy
- Neuropsychological testing
- Outpatient detoxification
- Psychiatric home care services
- Psychological testing
Eligible travel expenses require precertification in order to receive reimbursement.
This Web site summarizes many of the changes you can expect in your health plan as of January 1, 2014. It is not possible to address every circumstance. If you have questions about how the transition will specifically affect your situation, please contact Aetna's Health Concierge at (855) 784-8646. In case of a conflict between this newsletter and the official health plan documents, the plan documents will determine your benefits.