Health Insurance Plan Options

Post-65 Plans

Emeriti Health Plan VI – New Private Fee-for-Service Plan

(Replacing the former Plan VI – Aetna's Golden Medicare HMO)

Emeriti is pleased to offer a nationally available Medicare Part C insurance option, beginning in 2007. Called a Private Fee-for-Service Plan, this Medicare Advantage plan is an alternative to Original Medicare and the typical HMO arrangement associated with Medicare Part C.

• How Private Fee-for-Service Plan Works
• Aetna Special Programs
• Formulary Drug List
• Frequently Asked Questions List

For more information please review the Private Fee-for-Service Plan Summary of Plan Benefits.

To estimate your health care expenses in retirement, use the Retirement Health Care Cost Calculator.

More information on Medicare can be found on the Henry J. Kaiser Family Foundation Website, or by visiting Medicare.Gov.

To calculate the monthly premiums for the different 2007 Emeriti Health Insurance Plan Options, use the Emeriti Online Premium Rate Guide.

The Emeriti Program provides these distinctive features:

• Catastrophic protection
• A choice of Medicare-approved Part D prescription drug coverages
• Coverage of any doctor or facility that accepts Medicare
• National access to insurance
• Annual choice among Emeriti Health Insurance Plan Options
• Preventive care
• Urgent or emergency coverage for up to six months while traveling abroad.

Emeriti Health Plan VI – Private Fee-for-Service Plan
How Private Fee-for-Service Plan Works

One of the hallmarks of the Emeriti Program is to provide nationally available insurance that can move with you as you relocate throughout the country. We think that this portability is very important to many in the academic community. HMOs, however, are inherently local; if you relocate, you must find a new program.

The new Private Fee-for-Service Plan is similar to the Medicare Advantage HMO in that you assign your Medicare Part A, B, and D coverage to a private insurer, who agrees to provide all of the benefits of Original Medicare. Substantial preventive care benefits are also included, which Original Medicare does not provide. In addition, the Private-Fee-for-Service Plan has many of the advantages of traditional indemnity plans, in that there is no network and no gatekeeper; you can go to any provider or facility that agrees to accept payment under this type of plan.

In the Private Fee-for-Service Plan, the individual continues to pay the premium for Part B directly to Medicare, and pays a monthly plan premium to the insurer (Aetna) for comprehensive coverage, including the Part D prescription drug benefit.

Medicare annually determines the fee it will pay to all Private Fee-for-Service insurers on a county-by-county basis, and the rate may vary considerably from one adjacent county to another. The Medicare reimbursement rate also may vary considerably from one year to the next. Generally, the higher the Medicare payment in a particular county, the smaller the premium charges to the individual.

As in Original Medicare, providers and facilities decide whether or not to participate in a Private-Fee-for-Service Plan. Because it is a relatively new type of arrangement, some providers may not be aware of it. Consider providing your providers with information on this Plan VI section of Emeriti’s website, together with the attached Plan VI brochure

Before you choose this plan option, be sure that your doctor or other health care providers will be willing to participate. Aetna handles all claims reimbursements and allows providers who do not take assignment with Medicare to balance bill up to the Medicare-allowable limit of 15% of covered services. This is the same balance billing provision that exists today under Original Medicare fee-for-service.

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Emeriti Health Plan VI – Aetna Pharmacy Management
How Prescription Drug Coverage Works

The Aetna Pharmacy Management plan is Medicare-approved Part D coverage that helps you pay for prescription medications at retail pharmacies (for short-term prescriptions) or through Aetna's mail order service (for long-term prescriptions). The plan uses different levels (or "stages") of cost sharing. Here's how it works:

• Stage 1: You meet an annual deductible of $265.
• Stage 2: You pay a copayment for each prescription until the total amount paid by you and the plan combined reaches $2,400. Your copayment depends on the type of drug prescribed, as follows:
        $5 for generic drugs on the formulary list
        $35 for brand-name drugs on the formulary list
        25% coinsurance for specialty medications on the formulary
  You pay the full cost of drugs that are not on the formulary. For a list of formulary drugs, click here.
  
• Stage 3: You pay 100% of drug expenses until your out-of-pocket costs reach $3,850.
• Stage 4: If your true out-of-pocket expenses (the total of Stages 1, 2 and 3) exceed $3,850 in a given calendar year, you pay $2.15 (generic) or $5.35 (brand-name) for each prescription OR 5% of the prescription cost, whichever is greater, for the rest of the year. The plan pays the rest of the cost. The plan will only pay for preferred drugs (drugs on the formulary). You will continue to pay the full cost of drugs not on the formulary.

The preliminary abridged Aetna Formulary Guide is available in anticipation of the final Open and Closed Formularies being available for 1/1/07. Refer to the Closed Formulary section of the Formulary Guide for Plan VI prescription drug coverage. Aetna members will get the Aetna 2007 Formulary Guide in their Welcome Kit which is mailed out within 45 days of enrollment in an Aetna plan.

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Emeriti Health Plan VI – Aetna Pharmacy Management
How to Fill Your Prescriptions

There are two ways to fill prescriptions with the Aetna Pharmacy Management plan:

• You may fill short-term prescriptions (for a one- to 30-day supply) at retail pharmacies that belong to Aetna's network. You can use DocFind^® to locate participating pharmacies near you. When you visit the pharmacy, show your Aetna ID card. If you haven't met your deductible, you'll need to pay the full cost of the prescription unless you are using a Medicare prescription drug card or other discount program. If you've met your deductible, the pharmacist will know how much to collect for your share of the cost. Important: You must visit one of Aetna's 53,000 participating pharmacies in order to receive prescription drug benefits.
• You may fill long-term prescriptions (for a 31- to 90-day supply) through Aetna Rx Home Delivery,^® Aetna's mail order service. When you enroll, you'll receive information about this service, including how to order. When you order, Aetna will bill you for your medication if your share of the expense is $100 or less. If your share is more than $100, Aetna will contact you with cost and payment information. Your medication will be mailed once Aetna has received your payment. You can order refills by mail, phone or online at Aetna Navigator.

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Emeriti Health Plan VI – Private Fee-for-Service Plan
Aetna Special Programs

As Aetna members, you and your covered dependents may take advantage of special programs that address specific health conditions and needs. Click on the link(s) below to learn more, or click here for a full description of each program.

• Alternative Health Care Program – discounts on alternative therapies (such as acupuncture), vitamins and nutritional supplements, and natural products (such as aromatherapy, foot care and body care products).
• Fitness Program – discounts on health club memberships and certain exercise equipment through GlobalFit™.
• National Medical Excellence Program^® – support care coordination and other services when you or a covered family member needs an organ transplant or other complex medical procedure. For more information about the National Medical Excellence Program (including how to participate), call the toll-free Member Services number on your Aetna ID card.
• National Advantage Program – special rates and discounts with doctors, hospitals and ancillary providers.
• Vision One^® Discount Program – discounts on eye care products, including eyeglasses, contact lenses and solution, non-prescription sunglasses and other eye care accessories, and LASIK surgery.
• Women's Health Program – benefits that focus on the unique health care needs of women; for example, annual OB/GYN exams and cancer screenings.
• Informed Health Line – toll-free access to nurses who can provide information on medical conditions and treatment options, plus help with questions for your doctor.

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Emeriti Health Plan VI – Private Fee-for-Service Plan
Frequently Asked Questions

Here are common questions about the Private Fee-for-Service Plans. For other questions, call 1-866-EMERITI (1-866-363-7484).

How does a Private Fee-for-Service Plan compare with a Medicare Advantage Health Maintenance Organization (HMO) under Medicare Part C?

In both plans, Medicare contracts with private insurers to provide Original Medicare services. With a Medicare Advantage HMO, you select a primary care physician who oversees your treatment; and, except for emergency situations, you must stay within the network of providers and facilities and receive referrals in order to obtain covered services. Providers participating in the HMO network agree that their fees will not exceed the insurer’s established fee structure without prior authorization. Most HMOs are limited to specific geographic areas; if you move out of the area you will need to find other insurance coverage.

A Private Fee-for-Service Plan has no gatekeeper and no network. Each provider or facility must agree to accept the terms and conditions of payment according to Private Fee-for-Service Plans. It is up to you to make sure that your doctors and facilities are aware that you are enrolled in a Medicare Advantage Private-Fee-for-Service Plan so they may review and agree to accept these terms and conditions of the plan. Physicians who do not take assignment with Original Medicare may balance bill up to the Medicare-allowable coverage limits (15%). The Private Fee-for-Service Plan is available nationally, which means that wherever you live or relocate you may continue to be part of the plan and you will have open access to any provider who is eligible for Medicare and willing to accept the Private Fee-for-Services Plan.

How does a Private Fee-for-Service Plan compare in terms of benefits with an indemnity plan that builds on Medicare, like the Emeriti Plans I, II and III?

The Private Fee-for-Service Plan must offer the same benefits as Original Medicare. With a Private Fee-for-Service Plan, the insured participant has no deductible, but pays a copayment for each service, and the insurer pays the rest of the cost. A copayment is required for every doctor’s visit, every drug, etc., with no catastrophic threshold. Generous preventive benefits are included in the plan for $0 copayment. Part D benefits are also included.

With an indemnity plan, Medicare is involved as the first payor for hospital, physician, and other benefits provided under Original Medicare Part A and Part B. When Medicare does not pay the entire cost of a covered benefit, the insurer and the insured participant share the remaining cost. With the Emeriti plan options underwritten by Aetna, the participant pays the appropriate initial annual deductible under the plan for medical benefits, and then pays 20% of the balance, with Aetna paying the rest, until the plan reaches the annual out-of-pocket catastrophic threshold under the plan, Aetna will pay 100% of the remaining covered expenses for the balance of the calendar year. The insured participant’s cost share for Part D prescription drug benefits varies according to the selected standard or enhanced plan design option. The Emeriti plan options include both types. Indemnity plans generally provide limited, if any, preventive care benefits. The Emeriti Plans I, II and III provide allowances for annual physicals, and periodic routine eye and hearing exams.

The Private Fee-for-Service Plan and the three comprehensive indemnity plans offered by Aetna under the Emeriti Program all include the provision that participants will be covered for emergency or urgent care anywhere in the world for up to six months a year. (Medicare does not normally cover medical expenses incurred outside of the U.S.) Participants will also be able to add dental coverage from Aetna to any of the Emeriti insurance options for an additional premium.

What if the premiums for my Private Fee-for-Service Plan go up next year, or I want to switch to a provider who does not accept Fee-for-Service Plans?

Medicare determines the fee it will pay to insurers on an annual basis. The fee can change significantly, up or down, which will directly affect the premium that Aetna will charge for the coverage for the following year. If you decide for any reason that you no longer want to participate in the Private Fee-for-Service Plan, you can switch to another available Emeriti option for the following calendar year. The open enrollment period will be from around October 15th until December 31st each year, with coverage effective on January 1.