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The following questions and answers provide further basic information concerning the City of Scottsdale health benefits plan.
What is self-insurance?
What is the difference between an HMO and an EPO?
What is a PPO?
Will my social security number be displayed on my ID card?
Can I get to the online sites for the Aetna and MMSI?
How will the prescription drug plan work for the health plans?
What does non-formulary mean?
What about disability and life insurance?
How can I get help with a question or advice on my choices?
How can I get my family involved?
Is the period of time to satisfy the deductible and out-of-pocket maximum 18 months or is it 12 months?
What are the deductibles under the plans?
What expenses count when determining when the deductible has been met?
What expenses count towards satisfying the out of pocket maximum?
Are there separate deductibles and out-of-pocket maximums for in-network and out-of-network expenses?
What's the difference between the individual and family deductibles?
What's the difference between the individual and family out-of-pocket maximums?
How do I know if my doctor participates in the Plan's networks?
What is self-insurance?
Self-insurance means that payments for claims are being made by the city of Scottsdale rather than by an insurance company. In the three medical plans, the providers (MMSI or Aetna) process claims and provide customer service on behalf of the city but the money for actual claim payments comes from the city. However, the city is protected by stop loss insurance if claim costs are greater than expected. MMSI and Aetna also provide plan participants with various services such as use of their networks, case management, and other services such as the nurse line and disease management programs.
From the consumer's perspective, there is really no difference between the two. HMO stands for health maintenance organization while EPO stands for exclusive provider organization. The general premise of HMO's and EPO's is the same in that members must use the providers in the plan's network to receive benefits under the plan. The technical difference is that generally an HMO is an insured product (the insurance company pays the claim costs) whereas an EPO is generally a self-insured product (the employer pays the claim costs). Since the City of Scottsdale's plan is self-insured, it is technically called an EPO.
A PPO is a preferred provider network. This means that the plan offers two levels of benefits coverage: in-network benefits and out-of-network benefits. If a member uses providers within the plan's network (in-network benefits) they receive a higher level of coverage than if they use providers who are not within the plan's network (out-of-network) benefits. This differs from an HMO or an EPO in that in an HMO or EPO out-of-network coverage is not available.
No it will not. You will be given another unique identifier.
Yes. Even if you do not have authorization for general Internet access, the Information Systems Department is providing limited access for all city employees for the provider web sites listed under BeneFacts. Employees can also access those web sites from a home computer. To obtain information on Aetna go to www.aetna.com
and to access MMSI go to www.mmsiservices.com.
The prescription drug plans will be handled through each of the health plans. You will pay a specific percentage of the cost (with a minimum and maximum) for each tier (generic, brand and non-formulary) under the drug plan. In addition, all health plans provide a mail order drug program, which is a cost effective way to fill your prescription for maintenance medicines.
Each insurance plan has a preferred listing of drugs for the plan. That listing is called a formulary. If a drug is not on the health plan's preferred listing it is considered a non-formulary drug. If you are prescribed a drug which is not on the plan's formulary, you can still get that drug, however, you will pay more than for a drug which is on the formulary. If you are taking a drug that is not on the formulary, you may want to consult with your doctor to find out if there is a formulary drug that you could take instead.
The city provides benefited employees a basic life insurance benefit as well as short-term disability insurance and supplemental life insurance. Fee schedules are included under the Disability Benefits link.
Voluntary and Basic Life insurance does reduce upon attaining a certain age. Please see your certificate for details on those reductions.
The HR staff is ready to help. Employees can send e-mails to hr@ScottsdaleAz.gov, call (480) 312-7600 or stop by the HR office at 7575 E. Main Street.
The Benefits web site is available to anyone with an Internet connection at home. Family members who need specific information also are invited to contact HR through e-mail, by phone, or by dropping in at an HR office location.
What period of time is used to satisfy the deductible and out-of-pocket maximums?
All plans are on a fiscal year and the period for satisfying deductibles and out-of pocket maximums are based on a July through June 30 fiscal year.
Aetna EPO - there is no deductible.
MMSI - You must meet a deductible before the plan begins paying for many procedures. However, you should note that you do not need to satisfy a deductible under the MMSI plan before the plan will pay for in-network office visits or for the prescription drug benefit. For in-network office visits you only pay a co-pay and the plan pays the rest. Thus, if you visit a network primary care physician and the visit costs $100, you pay $15 and the plan pays the rest.
The deductibles under the MMSI Plan are: $500 for an individual/$1,000 for the entire family for in-network benefits and $2,000 for an individual/ $4,000 for the entire family for out-of-network benefits.
Aetna PPO - You must meet a deductible before the plan begins paying for most procedures. The deductibles under the Aetna PPO plan are: $1,750 for an individual, $3,500 for the entire family for in-network benefits; and $3,500 for an individual, $7,000 for the entire family for out-of-network benefits.
The expenses you pay for covered medical care other than co-pays and prescriptions are counted in determining when your deductible has been met.
Under all plans, the deductible, co-payments and co-insurance for medical services count towards your out-of-pocket maximum.
Prescription drug co-payments and any co-payments and co-insurance under CIGNA Behavioral Health do not count towards your out-of- pocket maximum.
Any expenses for medical services or supplies that are not covered by the Plan, and all charges in excess of Usual and Customary do not count.
Yes, there are separate deductibles and out-of-pocket limits for in-network and out-of-network benefits. The expenses you incur for in-network benefits only accumulate towards your in-network deductible and out-of-pocket maximum. The expenses you incur for out-of-network benefits only accumulate towards your out-of-network deductible and out-of-pocket maximum.
For example, if you have already met your in-network deductible, and then decide to go out-of-network for surgery, you would have to start accumulating out-of-network expenses towards your out-of-network deductible and out-of-pocket maximum.
The individual deductible is the amount of expenses that one individual must accumulate before their deductible is met. The family deductible is the amount that the all covered family together must accumulate before the deductible is met for all family members. Once the family deductible is met, no individual family member needs to accumulate additional expenses towards their deductible.
For example, if under the MMSI PPO plan, one member of your family accumulates $500 of in-network expenses, their in-network deductible has been met. Then, if a second covered family member accumulates $500 of in-network expenses, their in-network deductible is met as is the in-network deductible for any other family member since the family has met the $1,000 in-network deductible. The family in- network deductible could also be met, for example, if one covered family member had $300 in in-network expenses, another had $450 and a third had $250. Since the $1,000 family in-network deductible is met, all covered family members have met their in-network deductible.
This works the same way as the individual and family deductibles work. The individual in-network out-of-pocket maximum is the amount of expenses that one individual must accumulate before their in-network out-of-pocket maximums is met and the plan begins paying 100% of covered charges. The family in-network out-of-pocket maximum is the amount that the all covered family together must accumulate before the in-network out-of-pocket maximum is met for all family members and the plan begins paying 100% for all covered family members. Once the family in-network out-of-pocket maximum is met, no individual family member needs to accumulate additional expenses towards their in-network out-of-pocket maximums.
For example, if under the MMSI PPO plan, one member of your family accumulates $3000 of in-network expenses, their in-network out-of-pocket maximum has been met. Then, if a second covered family member accumulates $3000 of in-network expenses, their in-network out-of-pocket maximum is met, as is the in-network out-of-pocket maximum for any other family member since the family has met the $6000 in-network out-of-pocket maximum. The family in- network out-of-pocket maximum could also be met, for example, if one covered family member had $1500 if in-network expenses, another had $2500 and a third had $2000. Since the $6000 family in-network out-of-pocket maximum is met, all covered family members have met their in-network out-of-pocket maximum.
There are several ways that you can find out if your doctor participates in one of the Plan's networks. Because all networks experience some change in provider participation, the most reliable way to find out if a doctor is currently participating in a network is to contact the plan directly either through their web site or member services. This will provide you with the most up-to-date information. Printed provider information can become outdated very quickly, it is always a good idea to check with the plan or with your doctor prior to each visit to confirm that they are participating in the network.
This guide represents a summary of benefits provided by the City of Scottsdale to benefited employees. Every effort has been made to report information accurately. All information, including the amount of any benefit and employee eligibility of benefits, is subject to and governed by the terms and conditions of the applicable policy or plan documents. In all cases where any of the information provided in this guide differs from the amount of benefit actually provided by the policy or plan, the terms of the legal documents will control.