Shirlee Zerkel: Questions for Greg Nickell re: the Aetna Medicare Plan

From Shirley Zerkel, November 8, 2009
Subject: Some real concerns about the Aetna Medicare Plan!

Dear Mr. Nickell:

After attending a meeting in Lima sponsored by STRS concerning the Health Care Choices for 2010, I feel I still need more clarification on some concerns. I also went to Aetna's booth at that meeting and was given a booklet entitled "Aetna Medicare Enrollment Information." It had Aetna Medicare in the left top corner and the STRS Ohio in the right top corner. A number that appears to be an ID number is 58 32 305 1-ORSSTRS. Most pages in the booklet have no numbers so I will explain my questions as best I can. Because of the information at the meeting and what is stated in this booklet, I have several major concerns and yet I have to make a decision before November 24. I need some answers very soon.

1. We did not receive a list of vision and hearing screening places. Why?

2. No information was given about where discounts for eyewear or hearing aids. Why?

3. I received a list of Wellness facilities for the Lima area, but people in Columbus did not. Why?

4. On the 5th page that has writing on it, titled Aetna Medicare Plan (PPO) Approved Network Service Area Listing. The following shows a list of approved counties that are included in the Aetna Medicare service area as of January 1, 2010. My county and every county that borders mine is not on that list.

What does that mean for those of us living in that county?

Must we travel over 70 miles for a doctor or approved facilities?

The hospital I usually go to is not on their online list for Allen County; what do I do?

5. How do we retirees know which retail pharmacies are participating Medicare ones. (page 12 as I counted)?

6. Does the $1,500 a year out-of-pocket costs for retirees include the $15 doctor co-pay? (page 13 or 1, as this page has a number).

7. Who decides what is medically necessary? (page 15/3 as this page has a number)

8. Is no cosmetic surgery covered in this policy? (page 17)

9. What is meant by the following definition? (page 17) "Inpatient Hospital Deductible -- the amount of covered inpatient hospital expenses you pay for each hospital confinement is in addition to any other copayments or deductibles under your plan"

10. What is meant by the Emergency Room Deductible -- same description as above on Page 17?

11. Is our Aetna Medicare Plan a Direct Access/Open Access one? Please explain.

12. Does our STRS Aetna Plan require precert for hospitalization and other services such as doctors, etc? (page 19.)

13. The following is on page 19. "If your Aetna plan allows you to go outside the Aetna network of providers, you will have to get that approval yourself. In this case, it is your responsibility to make sure the service is precertified, so be sure to talk to your doctor about it. If you do not get proper authorization for out-of-network services, you may have to pay for the service yourself. You can not request precertification after the service is performed. To precertify services, call the number shown on your Aetna ID card." Please explain what is meant here.

What if a patient were taken to the hospital after an accident and was unable to call to precert. We are not always conscious at such a time?

14. Page 24 states "How Aetna Pays Out-of-Network Providers Some of our plans pay for services from providers who are not in our network. Many plans pay for services based on what is called the "reasonable, " "usual and customary" or "prevailing" charge. Other plans pay based on our standard fees for care received from a network provider or based on a percentage of Medicare's fees. Which one is the STRS plan?

15. "When we pay less than what your provider charges, your provider may require you to pay the difference. This is true even if you have reached your plan's out-of-pocket maximum" Please explain?????

16. Will our STRS plan use the Prevailing Charge Plan or the FEE Schedule Plan?

17. During the question and answer period of the meeting, a question was asked by a retiree in front of me: "What if my long time doctor was in the plan at the beginning of the year or agreed to bill the plan and then six months later, he decided to leave the plan? Can I then leave the STRS Medicare Plan?" Ms. Cole clearly stated that this retiree could. According to my Medicare and You manual from Medicare this is not true. What ever program a person goes with for the coming year is what they will have to stay with for that year. That was clearly confusing to me; please explain.

I am a very confused retiree at this point and a worried one,
Shirlee Zerkel