Frequently Asked Questions
Answers to the most frequently asked questions about 2017 benefits.
How is the Aetna Wichita Preferred Quality Point of Service (QPOS) network different?.............................. 2
What does a Primary Care Physician (PCP) role look like? ............................................................................... 2
How do I select a Primary Care Physician (PCP) for myself and dependents on the plan?........................... 2
Can I select a Physician Assistant (PA), Advance Registered Nurse Practitioner (ARNP) or a Specialist
as my Primary Care Physician? ............................................................................................................................ 2
Can I select my OB/GYN as my Primary Care Physician (PCP)? ...................................................................... 2
Can I designate more than one Primary Care Physician (PCP)? ....................................................................... 3
What happens if I want to continue seeing my out-of-network Primary Care Physician (PCP)? .................. 3
What if I don’t select a Primary Care Physician (PCP) for myself and dependents on the plan? .................. 3
Can I change my Primary Care Physician (PCP)? ............................................................................................... 3
When I change my Primary Care Physician (PCP), when does it become effective? ..................................... 3
Will I receive a new ID card each time I change my Primary Care Physician (PCP)? ..................................... 3
Do I have an option to see out of network providers with the QPOS plan? ..................................................... 4
Do I need a referral for every service? ................................................................................................................. 4
How do I obtain a referral and do they expire? ................................................................................................... 5
Can I obtain a referral to a specialist from my current Primary Care Physician (PCP) who will no longer
be in the network for 2017? ................................................................................................................................... 5
Do I need a referral to see a covering Primary Care Physician (PCP) within the same office? ..................... 5
Do I need a referral to continue seeing my mental health provider? ................................................................ 5
Is a Chiropractor considered a specialist? .......................................................................................................... 5
Do I need to get referrals starting in 2017 for a specialist I have already been seeing in 2016? ................... 6
What happens if a specialist has to send me to another specialist? ................................................................ 6
Can the specialist I’ve been referred to order diagnostic testing, such as an MRI?....................................... 6
What happens when my dependents reside in a different location than my family on a permanent basis? 6
Is the $100 cash option benefit still available? ................................................................................................... 6
Can I receive the cash option and still elect dental coverage? ......................................................................... 6
If my spouse and I both work for the district, can we both elect medical coverage? ..................................... 6
What is the dental deductible? .............................................................................................................................. 7
Is the formulary list of covered prescriptions different for each plan? ............................................................ 7
What does the prescription out of pocket maximum mean? ............................................................................. 7
Why is the prescription out of pocket maximum a higher amount on Plan Option 1 then Plan Option 2? .. 7
Do my dependent children need to get wellness points? .................................................................................. 7
Can I enroll in flex spending if I don’t enroll in the health plan? ....................................................................... 7
How do I provide verification of wellness points for myself and/or spouse? .................................................. 7
What if I have completed wellness activities that are not reflected in the system or have pending
appointments scheduled for wellness items before December 31, 2016? ....................................................... 8
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How is the Aetna Wichita Preferred Quality Point of Service (QPOS)
network different?
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You will be required to select an in-network primary care physician (PCP) for yourself and
dependents on the plan during open enrollment.
You will need to obtain referrals from your PCP before seeking care from a specialist.
You can seek care from out of network providers but may be required to pay more out of your
pocket.
What does a Primary Care Physician (PCP) role look like?
A primary care provider (PCP) is your primary partner for your health. Your PCP focuses on your overall
health, making sure you get recommended screenings and risk assessments, focusing on wellness and
prevention. A PCP also helps navigate you through your medical care options; providing referrals to
specialist and/or specialized services based on specific health care needs you may have.
How do I select a Primary Care Physician (PCP) for myself and
dependents on the plan?
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During open enrollment you will be required to select a primary care physician (PCP) for you and
each of your covered dependents and enter that information in order to complete your enrollment.
To find in-network providers who are accepting new patients, click here:
Aetna 2017 Primary Care Providers List
If you would like assistance in finding a PCP please contact the district provided nurse navigator at
(316)347-1527 to assist you in choosing and transitioning to another primary care physician. You
can also reach the nurse navigator by sending an e-mail to [email protected].
A list of in-network PCPs will also be available within the online enrollment system.
Can I select a Physician Assistant (PA), Advance Registered
Nurse Practitioner (ARNP) or a Specialist as my Primary Care
Physician?
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Your PCP must be a physician – (Family Practitioner, Pediatrician, Internal Medicine or General
Practitioner).
You can see a Physician Assistant (PA) or Advance Registered Nurse Practitioner (ARNP) who works
under your selected PCP but you cannot designate a PA, ARNP, or Specialist as your PCP.
Can I select my OB/GYN as my Primary Care Physician (PCP)?
No, your PCP can not be your OB/GYN due to the referral requirements that are associated with the
PCP position. Eligible provider types for selection of a PCP include:
• Family Practitioner
• Pediatrician
• Internal Medicine
• General Practitioner
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Can I designate more than one Primary Care Physician (PCP)?
No, each member on the plan can only one PCP and would need a referral to another physician.
What happens if I want to continue seeing my out-of-network
Primary Care Physician (PCP)?
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An out of network provider cannot be designated as your Primary Care Physician (PCP).
You would still need to designate an in-network PCP during Open Enrollment; otherwise Aetna
will assign you one.
If you choose to see an out of network provider, you will be responsible for the out of network
deductible, out of network coinsurance and any amount above what is billed and what Aetna
allows for that service.
What if I don’t select a Primary Care Physician (PCP) for myself
and dependents on the plan?
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If you do not select a specific PCP during open enrollment, Aetna will assign one to both you and
your dependents.
If you are assigned a PCP automatically you will receive a letter from Aetna notifying you of this
auto assignment.
Can I change my Primary Care Physician (PCP)?
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You can change your PCP anytime and as many times as you would like.
You can change your PCP by calling 1-800-228-6481 and speaking to a representative.
When I change my Primary Care Physician (PCP), when does it
become effective?
Your PCP selection will be effective the first day of the following month.
Will I receive a new ID card each time I change my Primary Care
Physician (PCP)?
Yes, you will receive a new ID card each time you select a new PCP.
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Do I have an option to see out of network providers with the
QPOS plan?
You can seek care outside of the network that is aligned to your plan.
Remember - You will have higher out of pocket expenses
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Higher deductible
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Higher coinsurance percentage
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You can be billed for the difference between the billed charges and the allowed charges in
addition to your deductible and coinsurance.
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Even if you reach the maximum payment limit and begin to receive 100% benefit you can still
be responsible for the difference between billed charges and allowed charges.
• You may be required to obtain precertification or review for certain services
• You may be required to pay the bill and submit the claim to be considered under your plan of
benefits.
Do I need a referral for every service?
You will need a referral for all services except the following:
• Behavioral Health
• Durable Medical Equipment
• Gynecology care (routine, non-routine, pregnancy)
• Home Health Care
• Hospital Ambulatory Surgery
• Hospital Outpatient Services
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Midlevel practitioners
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Automated Ambulatory Blood Pressure Monitoring, Diagnostic Radiology, Dialysis/Hemodialysis,
Dysplastic Nevi Total Body Photography, Nuclear Medicine Procedures, Physical, Occupational & Speech
Therapy, Radiology
Physician Assistant, Nurse Practitioner – at the PCP’s office, or at the specialist offices (when a referral is
given to that in-network specialist)
Preventative Immunizations when given at the PCP’s office
Radiology, Pathology, Lab
Routine Vision Care
Physical, Occupational, Speech Therapy
Urgent Care Facility
Walk-In Clinic (Take Care Clinic, Little Clinic, etc.)
Nutritional Counseling
Termination of Pregnancy (Involuntary)
This is a summary of services provided in-network and may not be all inclusive. You may still need to
have a prescription or precertification for services whether or not they require a referral.
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How do I obtain a referral and do they expire?
Your in-network PCP is responsible for coordinating your care and issuing your referral. The PCP
authorizes referrals to participating providers, as required by the plan.
You are responsible to ensure the referral is on file before visiting the specialist.
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The referral will specify the timeframe and number of visits requested based on your specific
medical condition as designated by your PCP.
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A referral can be obtained for any Aetna in-network provider.
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A specialist can only provide services authorized by the referral. If more services are necessary,
the specialist or member must contact the PCP.
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The PCP can refer a member to a participating specialist using our electronic or paper referral.
The referral may authorize either:
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A consult and treat
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A consult only
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Specific services
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If you do not obtain a referral prior to seeking services, your claim will be paid as out of network.
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You can verify the referral is on file by calling customer service at 1-800-228-6481 as they are not
viewable through the Aetna Navigator.
Can I obtain a referral to a specialist from my current Primary
Care Physician (PCP) who will no longer be in the network for
2017?
No. Any referrals must be obtained from your 2017 designated in-network PCP.
Do I need a referral to see a covering Primary Care Physician
(PCP) within the same office?
You do not need a referral if your PCP is out of the office and your appointment is within the same
office with a covering PCP.
Do I need a referral to continue seeing my mental health provider?
No, you do not need a referral to receive care from in –network or Behavioral/Mental Health
providers.
Is a Chiropractor considered a specialist?
Chiropractic care has a co-pay of $30 (not the specialist copay), however you will need to obtain a referral from
your PCP to an in-network chiropractor.
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Do I need to get referrals starting in 2017 for a specialist I have
already been seeing in 2016?
Yes. Even if you have been receiving care from an in-network specialist in 2016, you will need a referral
from your in-network PCP to continue to receive in-network benefits with that specialist starting in
2017.
If you are treating with a specialist, who will no longer be in the network in 2017, you will need to
complete a Transition of Care form to request continuation of this care for a temporary period of time.
What happens if a specialist has to send me to another
specialist?
Most instances a specialist will work with your Primary Care Physician (PCP) to obtain a referral to
another specialist. However, there may be instances you may be required to contact your PCP to
obtain the new referral for the new specialist.
Can the specialist I’ve been referred to order diagnostic testing,
such as an MRI?
Yes, the in-network specialist that you have referred to can order diagnostic tests without having to obtain an
additional referral from your PCP
What happens when my dependents reside in a different location
than my family on a permanent basis?
If your dependents zip code is outside of the local network, they will be placed into an out of area plan,
and no PCP designation is required.
Is the $100 cash option benefit still available?
Yes. If you are enrolled in your spouse’s health insurance plan either through another employer or USD
259, you can elect the cash option benefit.
Can I receive the cash option and still elect dental coverage?
Yes. If you have proof of other medical coverage and waive the medical plan but enroll in dental, you
can still elect the cash option benefit.
If my spouse and I both work for the district, can we both elect
medical coverage?
Each employee can elect to cover themselves on their own plan. However, you cannot enroll each
other or your dependents under both plans. One of you can enroll the family under one employee,
and the other can enroll in the cash option.
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What is the dental deductible?
It is $50 per person or $150 for the whole family. An individual would not pay more than $50 in
deductible.
Is the formulary list of covered prescriptions different for each
plan?
No, the only difference in the three plans is the out of pocket maximum.
What does the prescription out of pocket maximum mean?
For example if the prescription out of pocket maximum is $1000, once a member pays out co-pays that
total $1000, covered prescriptions would be paid at 100% the remainder of the calendar year.
Why is the prescription out of pocket maximum a higher amount
on Plan Option 1 then Plan Option 2?
To be in compliance with the cost-sharing limits under the ACA, the out-of-pocket costs for essential
health benefits cannot exceed the annual cap of $7,150 for individual and $14,300 for family.
When a plan has a higher medical out of pocket cost, the prescription out of pocket will be lower as to
not exceed the maximum out of pocket limits.
All three (3) medical plan options for 2017 have lower out of pocket prescription maximums than the
current maximums in place on current plan which is $3,000 for individual and $6,000 for family.
Do my dependent children need to get wellness points?
No, it only applies to the employee and covered spouse on the health plan.
Can I enroll in flex spending if I don’t enroll in the health plan?
Yes, the flex spending enrollment is completely separate from the health plan enrollment but will also
be part of Open Enrollment.
How do I provide verification of wellness points for myself and/or
spouse?
The online system will have points for those wellness services completed since January 1, 2016 under
the current health plan verified for you. For those credits completed after October that may not be
captured in the system, you can simply upload supporting documentation during open enrollment or
fax that documentation to employee benefits at 973-4646 labeled with your name and employee ID.
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What if I have completed wellness activities that are not reflected
in the system or have pending appointments scheduled for
wellness items before December 31, 2016?
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You can upload a copy of your appointment card for pending appointments during open
enrollment as pre-verification of those wellness points.
You can provide other verification documentation as well such as Explanation of Benefits (EOBs),
receipts for services, etc.
Anyone who attests to be a non-tobacco user during online enrollment will be given 25 wellness
points for being a non-tobacco user and will be subject to random audit and confirmation testing,
paid for by the district, of non-tobacco status.
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