Medical Benefits

MEDICAL PLAN OPTIONS

Under Individual Choice, you may elect one of two medical options. In addition, if you have medical coverage elsewhere (for example, under your spouse's plan), you may decline medical coverage. Unless you have coverage elsewhere, you must select one of the medical plans.

Both medical plans cover the same kinds of expenses — hospitalization, surgery, physician's office visits, prescriptions, and the like. The differences between the plans include the amount of the expenses you pay out of pocket and the cost of the options.

You may choose from five coverage categories, as follows:

• Employee only
• Employee and Spouse or Qualified Domestic Partner
• Employee and children
• Family
• Shared Family (when both you and your spouse or qualified domestic partner work for Ithaca College and you have eligible dependent children; if you do not have dependent children, each employee must select "employee only" coverage)

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FIND A PROVIDER IN-NETWORK AND PAY LESS

Each medical option provides coverage through a network of doctors, hospitals, and other providers who have arranged to deliver their services to Ithaca College employees. The network providers were selected based on their quality of service, commitment to managed care, and willingness to accept specific fees for services. You may use out-of-network providers, although their costs and the expense to you may be higher.

A listing of in-network providers is available by calling Aetna directly or viewing Aetna's DocFind on their website. The following additional advantages apply when you use in-network providers:

• All costs for services received from in-network providers fall within reasonable and customary limits.
• Examples of some of the preventive services that are covered (see the medical plan Summary of Benefits for frequency and further details):
  • Routine physical exams
  • Immunizations
  • Routine eye exams
  • Routine hearing exams
• You do not submit any claim forms for office visits.
• In-network providers are responsible for handling any preadmission certification requirements for hospital stays.

When enrolling in either medical plan, choosing a Primary Care Physician (PCP) is not required but is strongly recommended. Establishing a relationship with your PCP will help to insure effective coordination of your medical care. You do not need a referral to see a specialist when enrolled in either plan.

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AETNA OPEN ACCESS POS II PLAN

Under the Aetna Open Access POS II Plan a deductible must be met before most services are covered, in- and out-of-network benefits will be payable for services received anywhere in the country, the election of a primary care physician is not mandatory, although it is strongly recommended, and you don’t need to seek referrals to see a specialist. The plan has an annual out-of-pocket maximum that limits the amount you pay in a given year for covered expenses. When you seek care from an in-network provider, your out-of-pocket expenses are less. Covered services from an out-of-network provider are subject to a higher deductible and a lower reimbursement rate. Also review the section on emergency situations.

The Open Access POS II Plan allows you the freedom to seek care in one of three ways:

• Visit your Primary Care Physician (PCP) if you elected one; or
• Go directly to another in-network PCP or health care provider. You never need a referral if you seek care under this option; or
• Go directly to an out-of network physician or health care provider. When you choose this option, you do not need a referral; however, covered services from an out-of network provider are subject to a higher deductible and a lower reimbursement rate.

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AETNA HIGH DEDUCTIBLE HEALTH PLAN WITH A HEALTH SAVINGS ACCOUNT

The High Deductible Health Plan (HDHP) provides comprehensive health benefits for major medical costs and allows you to build savings, through a Health Savings Account (HSA).

Under the High Deductible Health Plan, a deductible must be met before most services are covered, in- and out-of-network benefits will be payable for services received anywhere in the country, the election of a primary care physician is not mandatory, although it is strongly recommended, and you don’t need to seek referrals to see a specialist. The plan has an annual out-of-pocket maximum that limits the amount you pay in a given year for covered expenses. When you seek care from an in-network provider, your out-of-pocket expenses are less. Covered services from an out-of network provider are subject to a higher deductible and a lower reimbursement rate. Also review the section on emergency situations.

Most preventive care services (screenings, physical exams, immunizations, etc.) are fully covered and are not subject to the deductible before benefits are payable under the HDHP. In addition, many preventive medications are fully covered after the applicable copay and are not subject to the deductible.

Pre-tax money accumulated in an HSA can be used for current or future medical expenses. If you don't use up your HSA during the calendar year, the account balance is rolled over to the following year. It also goes with you if you leave Ithaca College and ultimately can be used in your retirement.

To qualify for an HSA, you:

• Must be enrolled in the HDHP.
• Cannot be claimed as a dependent on someone else's tax return.
• Cannot be enrolled under any other medical plan.

As an HSA participant, you will be issued a debit card that can be used to reimburse all or any part of your qualified medical expenses. Your debit card can also be used at various point-of-sale locations.

Withdrawals from your HSA must be for HSA Qualified Medical Expenses, and are tax free. If you withdraw money for any reason other than for qualified medical expenses, you must pay income tax and a 10% excise tax. HSA monies must be in the account in order to be withdrawn. There is no minimum withdrawal from the HSA.

Money in your HSA can be invested once you reach a $2,000 balance. A monthly fee for the investment account is charged directly to the account holder once an investment account is established.

Participants who are 55 or older (until enrolled in Medicare) are eligible to make a catch-up contribution. A spouse eligible to make a catch-up contribution is required to set-up their own HSA by contacting Aetna Member Services.

HDHP participants are eligible to establish an HSA, but are not required to do so.

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WHEN YOU NEED TO PRE-CERTIFY SERVICES

Pre-certification for certain types of out-of-network care must be obtained to avoid a reduction in benefits paid for that care. Pre-certification applies for the following non-preferred care services: Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care, Durable Medical Equipment, Hospice Care and Private Duty Nursing. If pre-certification is not obtained, their will be a reduction in benefit per occurrence which will be applied separately to each type of expense. If services are provided by an in-network provider, he or she will be responsible for coordinating any pre-certification requirements.

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UNDERSTAND YOUR PRESCRIPTION DRUG PLAN

Prescription drugs are covered based on Aetna's Three-Tier/Open Formulary. A formulary is also known as a preferred drug list. The formulary is a list of preferred generic and brand-name prescription drugs that are covered under your plan benefits. Many drugs not on the formulary are also covered under the plan, but at a higher expense to you.

The amount you pay for a covered prescription drug depends on whether it is on the formulary, whether the drug is generic or brand-name, and whether you fill it at an in-network or out-of-network pharmacy. Please see the Pharmacy section of the Summary of Benefits for your medical plan for specific copay and reimbursement amounts.

If you have a chronic (ongoing) condition that requires more than a 30-day supply of prescribed medication, your prescription may be filled through a mail order program referred to as Aetna Rx Home Delivery. This program allows you to order medications that are taken to treat a chronic condition and pay fewer co-pays. Mail order envelopes are available from the Benefits Department office or online :Aetna RX Home Delivery form.

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IN CASE OF EMERGENCY

A medical emergency is generally considered to be a sudden and unexpected change in a person's physical or medical condition that is severe enough to require immediate hospital-level care. If you have a medical emergency that requires immediate treatment, both in-network and out-of-network benefits are covered the same. Treatment sought from an urgent care facility rather than an hospital emergency room is reimbursed at a higher level. Non-emergency use of the emergency room and non-urgent use of an urgent care facility is not covered. Please see the Emergency Care section of the Summary of Benefits for your medical plan of this booklet for specific co-pay and reimbursement amounts.

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TO DECLINE MEDICAL COVERAGE

If you have medical coverage under another plan, or a plan provided by your spouse’s or partner’s employer, you can decline medical coverage under the Individual Choice program and receive separate cashable credits. In order to decline coverage, you must certify that you have other coverage.

If you decline medical coverage under Individual Choice and subsequently lose your other medical coverage, you will be allowed to enroll in one of the Individual Choice medical options, provided your request for enrollment occurs within 30 days of the date your other coverage is lost. Verification may be required that your other coverage has been involuntarily terminated.

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HELP FOR CHOOSING THE RIGHT MEDICAL PLAN FOR YOU

Before choosing a medical option, these are some of the factors you may wish to consider:

• Do you have medical and dental coverage under another plan? If so, how do the coverage levels and costs compare to the Individual Choice options?
• If your spouse or partner has coverage and you are not currently covered under his or her plan, are there any restrictions for coverage (e.g., a waiting period before coverage begins, limits on coverage for a preexisting condition, etc.)?
• You do not have to cover the same family members for both medical and dental insurance. You can consider protecting different family members for medical benefits than you cover for dental benefits. For example, you can enroll yourself and your children for medical coverage, but choose to enroll only yourself in the dental option.
• What are your estimated medical expenses for the coming year? Do your family’s health care needs suggest more or less coverage is needed? What have your health care spending patterns been in the past?
• What level of out-of-pocket medical expenses can you handle comfortably?
• Is your doctor an in-network provider?

Online Tools to Assist your Choice

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