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S M T W T F S

Frequently Asked Questions


General

  1. Which is the best benefit option?
  2. Does the plan cover me if I am out of the country and need care?
  3. My doctor’s office doesn’t understand LabCard.
  4. What is my cost for each of the Plans?
  5. My ID card says Aetna.  Is that who my coverage is through?

 

Coordinated Health/Care

  1. What does my Health Care Provider have to do to submit a notification or pre-authorization?
  2. Why did the Plan start the Coordinated Health/Care program?
  3. Why do I have to have a Primary Care Provider (PCP)?
  4. Do I have to see my PCP in order to get a referral to a specialist?
  5. Do I have to get a referral in order to see a specialist?
  6. Can my OB/GYN be my PCP?
  7. What kinds of doctors can be a PCP?
  8. What do I have to do to get the enhanced office visit benefit?
  9. What does the enhanced office visit benefit include?
  10. I saw my doctor but did not get the enhanced benefit.  Why?
  11. How do my providers know what they need to do?
  12. What about mental health providers?

 

Preferred Provider Network

  1. How do I know which network to use?
  2. When I am traveling away from home or am outside of Tennessee, how do I find a provider?
  3. If I have a covered dependent, such as a child in college, who lives in another part of the country, how do they locate an in network provider?
  4. What if I have a medical provider who is not in my network?
  5. When I look up network facilities such as hospitals, what does it mean when certain types of procedures, like "Select CT" or "Select MRI" show in the right hand column?

 

Preventive Care

  1. Do I have to have all my routine annual care in one visit?
  2. Why can’t I just go to my OB/GYN for my annual visit without a referral?
  3. If I have a family history of breast cancer, why are mammograms still limited to one every other year until I am age 50?
  4. My doctor told me to have a second colonoscopy in three years.  Will that be covered under preventive care?

 

Prescription Drugs

  1. I thought the Plan used Express Scripts for prescription drug benefits but my ID card says "ScripWorld?
  2. I have just been contacted by some company called CuraScript about my medication. I thought our plan used Express Scripts?
  3. What are these enhanced benefits if I have a chronic medical condition?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Answers


General

 

  1. Which is the best benefit option?

    There is no one benefit option that is the best, or we would only offer it.  Each option has its own pluses and minuses and only by applying your individual facts can you decide which is best FOR YOU. Return to Top
     

  2. Does the plan cover me if I am out of the country and need care? 

    Yes.  Because health care billing in other countries does not operate the same way as in the US you will probably have to pay the bill yourself and submit it to the plan for reimbursement on your return.  The plan will determine the exchange rate in effect on the date of your services and pay at the in network benefit level. Return to Top
     

  3. My doctor’s office doesn’t understand LabCard.

    LabCard is a program the Plan has contracted with Quest Diagnostics.  When your provider sends your lab specimens to Quest under the LabCard program identification, charges are billed directly to the Plan at highly discounted rates, which allows the Plan to afford to pay 100%* of the charges and still be cost effective.  In this way both you the Participant and the Plan save money.Return to Top
     

    LabCard Select is the version of the LabCard program that applies to participants covered under the Qualified High Deductible Plan (QHDHP).  Since federal regulations do not allow such a plan to pay benefits (other than preventive) until the deductible has been met, Participants receive highly discounted rates for their lab work which applies to their deductible or to their coinsurance once they have met the deductible.Return to Top
     

  4. What is my cost for each of the Plans?

    The cost to Participants for each of the plan options is determined by each Member School based on their rates from the Consortium and their compensation strategy which includes how much employee compensation is direct (payroll) and how much is indirect (benefit subsidies).  Participants need to check with their Human Resources Department for benefits costs.Return to Top

  5. My ID card says Aetna.  Is that who my coverage is through?

The Aetna logo on your card simply identifies the network of providers the Plan uses, similar to the Express Scripts logo on the card.  Benefits are provided through the TICUA Benefit Consortium Health Plan.  The Plan contracts with Meritain Health to perform claims administration services.  Information on where claims are submitted, either electronically or by mail, are on the inside of the Plan ID card. Return to Top

 

 

Coordinated Health/Care

 

  1. What does my Health Care Provider have to do to submit a notification or pre-authorization?

    There are three ways a Provider can submit a notification or pre-authorization.   They can complete a form on line, they can print the form, fill it out and fax it in or they can call a Care Coordinator.  Information on all three ways are available on the Plan's website at www.ticua.org/tbc by selecting the drop down “Provider? Click here” under the tab “Provider Information”. Return to Top
     

  1. Why did the Plan start the Coordinated Health/Care program?

    The experiences of many other health plans have shown that those with programs resulting in high participant “touch” have lower than average rates of increase in their health care costs.  Equally important, the Coordinated Health/Care program has demonstrated its ability to improve the participants’ experiences with the plan through improved customer service and pro-active assistance in working their way through the “maze” that today’s health care system has become. Return to Top
     

  2. Why do I have to have a Primary Care Provider (PCP)?

    You do not HAVE to have a Primary Care Provider (PCP).  If you choose not to have a PCP you continue to receive the same benefits that have been in effect.  ONLY if you want to receive enhanced benefits for office visit charges do you need a PCP so you can have a place to start receiving medical care and from which to get a referral to a specialist. Return to Top
     

  3. Do I have to see my PCP in order to get a referral to a specialist?

    Whether you have to see your PCP or simply have a conversation over the phone will depend on a number of factors including:  your PCP’s normal procedures, how recently you have seen him or her, if you have a history with the specialist and what are your complaint/symptoms. Return to Top
     

  4. Do I have to get a referral in order to see a specialist?

    The Coordinate Health/Care program is voluntary.  Unlike the old “gatekeeper” approach, such as was used by HMOs, you are free to self-refer to a specialist of your own choosing.  HOWEVER, if you do not have a referral from a PCP you will not receive the enhanced office visit benefit. Return to Top
     

  5. Can my OB/GYN be my PCP?

    Normally your OB/GYN only serves as your PCP during pregnancy.  Other than during pregnancy OB/GYNs typically do not want to deal with other matters like sore throats, stomach pains, twisted ankles, and the like. However, if you want him/her to be your PCP AND you get him/her to let the Care Coordinators know of his/her agreement to serve in that role, your OB/GYN can then be your PCP. Return to Top
     

  6. What kinds of doctors can be a PCP?

    Normally PCPs come from “generalist” specialties like: Family Practice, General Practice, Internal Medicine, Gerontology, Family Nurse Practitioner, and Pediatrician (for children), as well as OB/GYN during pregnancy.  Although you are free to choose ANY doctor as your PCP, regardless of specialty or provider network participation, he or she will have to agree to serve in that role and he or she will have to contact the Care Coordinators to let them know.  ALSO, while you can choose a provider who is not in the provider network, you will receive the reduced out of network benefits for his or her services and the enhanced benefit does not apply. Return to Top
     

  7. What do I have to do to get the enhanced office visit benefit?

    In order to receive the enhanced office visit benefit you need to either see your PCP or receive a referral from your PCP to a specialist.  Depending on your PCP, referrals are generally good for a year, so you do not have to get a new referral from your PCP for each visit to that specialist. Return to Top
     

  8. What does the enhanced office visit benefit include?

    The enhanced office visit benefit applies to office visit charges and other charges made by that provider for services during the same visit, billed on the same bill with the office visit charges. Return to Top
     

  9. I saw my doctor but did not get the enhanced benefit.  Why?

    You will not receive the enhanced benefit if:

    • there is no office visit charge
    • some services are performed during a later visit (come back tomorrow for lab work)
    • services are billed on a different bill
    • your PCP did not communicate his/her referral to the Care Coordinators
    • services are provided by a different provider and/or are billed separately
    • the provider is not in the Plan’s provider network. Return to Top
  1. How do my providers know what they need to do?

    On the “inside” of your ID card is the basic information your providers will need, including your office visit benefit, how/where to check your eligibility, how to submit a referral, what procedures require pre-certification and how/where to submit claims. 
     

    One of the responsibilities of the PCP is to refer his or her patient to a specialist when the need arises.  The same enhanced office visit benefit is available for a specialist as for the PCP when the Care Coordinators have been notified of the referral by the PCP’s office.  The PCP has three ways to give the Care Coordinators this notification or referral:  call 888.559.2155; fax 800.973.2321, or; on the internet go to www.CHC-care.com.  If the PCP submits by fax, the information needed is: Patient Name and date of birth; Group Name and Insured ID number (both are shown on your ID card); Requesting Physician’s name, phone and fax numbers; Name of person completing referral information and date; Specialist’s name, phone and fax numbers; diagnosis; appointment date if known, and; scope of referral.  Additional information is needed for any of the procedures listed on the inside of your card as requiring precertification Return to Top
     

  2. What about mental health providers?

    Just like medical providers are grouped into PCPs and Specialists, mental health providers are grouped into PCPs and Specialists.  The following types of providers are considered by the Plan to be Mental Health PCPs and are eligible for the enhanced office visit benefit without a referral when providing treatment for mental health conditions and substance use disorders which are covered under the Plan:

    The same enhanced office visit benefit is available for a Mental Health Specialist as for the PCP when the Care Coordinators have been notified of the referral by the PCP’s office.  Mental Health Specialists include Psychologists and Psychiatrists
     

    • Psychiatric Nurse Practitioners
    • Licensed Clinical Social Worker (LCSW)
    • Licensed Master’s Social Worker (LMSW) working under LCSW supervision
    • Licensed Professional Counselor with or without Mental Health Services Provider (HSP) Designation
    • Licensed Psychological Examiner under supervision of Licensed Psychologist with HSP designation, and;
    • Licensed Senior Psychological Examiner. Return to Top

 

Preferred Provider Network

 

  1. How do I locate a provider in my network?

    First, if you are experiencing a life threatening emergency, don’t worry about a network provider.  Get the emergency care you need and the plan will cover it as if the provider is in network.
     

    On the “front” of your ID card (the side with your name, ID number and other plan information) you should see a “In-Network Provider Panel” box with the Aetna logo inside it.  Aetna's Open Choice© network is a nation-wide network of providers, so look for a provider in that network first, regardless of whether you are in your home location or traveling anywhere in the United States. Providers can be located be accessing the Plan’s website at www.ticua.org/tbc, selecting the drop down “Find a Medical Provider” under the tab “Provider Information” and clicking on the link associated with the network logo.  In some cases the Plan has contracted directly with providers who would not otherwise be considered in network.  To locate information on those providers go to the Plan's website at www.ticua.org/tbc, select the drop down “Find a Medical Provider” under the tab “Provider Information” and click on the link in the section "Additional Providers in Tennessee". Return to Top
     

  2. When I am traveling away from home or am outside of Tennessee, how do I find a provider?

    If you are traveling outside your home location and are away from your usual medical providers,you are not in your Primary provider network service area, first look for a provider in Aetna's Open Choice© network.  If you cannot find a provider there, look on the “back” of your ID card where you will see a “Travel/Out of Area” box with the PHCS network logo in it.  Providers can be located be accessing the Plan’s website at www.ticua.org/tbc, selecting the drop down “Find a Medical Provider” under the tab “Provider Information” and clicking on the link associated with the PHCS network logo.  If you are away from home but in Tennessee you may also want to check on "Additional Providers in Tennessee" on the “Find a Medical Provider” page. Return to Top
     

  3. If I have a covered dependent, such as a child in college, who lives in another part of the country, how do they locate an in network provider?

    Because Aetna's Open Choice© network is a nation-wide network of providers, they should look for a provider in that network first, regardless of where they are in the United States. Providers can be located be accessing the Plan’s website at www.ticua.org/tbc, selecting the drop down “Find a Medical Provider” under the tab “Provider Information” and clicking on the link associated with the Aetna network logo. Return to Top
     

    If they are unable to locate a provider close to them in the Aetna network they should search for one in the PHCS Travel/Out of Area network. Providers can be located be accessing the Plan’s website at www.ticua.org/tbc, selecting the drop down “Find a Medical Provider” under the tab “Provider Information” and clicking on the link associated with the PHCS logo. Return to Top
     

  4. What if I have a medical provider who is not in my network?

    If you are new to the Plan and you already have a health provider who is not in your preferred provider network, you can nominate that provider to be added to the network.  We will work with the network to try to get your provider added.  If the network will not add your provider for reasons other than credentialing (licensing, complaint history, practice problems, etc.) we will consider offering to contract with him or her directly, as we have with other providers. Return to Top
     

  5. When I look up network facilities such as hospitals, what does it mean when certain types of procedures,like "Select CT" or "Select MRI" show in the right hand column?

Each designation off to the right means that the facility is considered by Aetna as one of the tops in quality for the specific area listed.  The facility is participating for ALL services and has achieved better than average outcomes in the area(s) listed. Return to Top

 

 

Preventive Care

 

  1. Do I have to have all my routine annual care in one visit?

    For children age five or older and adults, the Plan’s annual preventive care benefit has a dollar limit on it that may be used over one or more visits.  That dollar limit does not include certain other preventive care procedures such as immunizations, mammograms and colonoscopies, to name a few, which have their own separate benefit allowances.  Also, you can stretch the annual dollar limit by having preventive lab work done under the Quest Diagnostics LabCard program: LabCard charges are covered by the Plan at 100%* and payments are not considered part of the annual preventive benefit.  *under the QHDHP plan, not covered at 100% except for preventive care.  Other, non-preventive charges, are heavily discounted and subject to the QHDHP deductible and coinsurance. Return to Top
     

  2. Why can’t I just go to my OB/GYN for my annual visit without a referral?

    Your annual OB/GYN check up is covered under the Plan’s preventive care benefits and you do not need a referral from your PCP.  While you do not need a referral for any visits to your OB/GYN in order to receive the enhanced office visit benefit, you are encouraged to start with your PCP, or at the very least keep him/her informed when you have symptoms and are seeking treatment from your OB/GYN. Return to Top
     

  3. If I have a family history of breast cancer, why are mammograms still limited to one every other year until I am age 50?

    Where there is a history of breast cancer and the patient’s physician deems mammography screening as medically necessary, additional screenings beyond what is allowable according to the schedule are covered under the plan.  If the individual has a personal history of breast cancer these additional mammograms, if pre-notified in accordance with the rules, are covered under the wellness benefit while if there is a family history it is covered under the Plan’s general medical benefit, subject to applicable deductibles and coinsurance. Return to Top
     

  4. My doctor told me to have a second colonoscopy in three years.  Will that be covered under preventive care?

    Generally if a colonoscopy shows no unusual results and there are no other reasons for more frequent monitoring, additional procedures are scheduled between five and ten years later.  If your physician has recommended a repeat procedure in less than five years there may be any number of reasons.  In such cases where the physician deems a follow up colonoscopy in less than five years to be medically necessary, it will be covered under the Plan’s general medical benefit, subject to applicable deductibles and coinsurance.  Remember that the Plan does require precertification of colonoscopies. Return to Top
     

Prescription Drugs

 

  1. I thought the Plan used Express Scripts for prescription drug benefits but my ID card says "ScripWorld?

In order to get the most competitive pricing on prescription drugs the Plan has contracted with a firm named ScripWorld which has contracts with several Pharmacy Benefits Management (PBM) firms, including Express Scripts.  Your pharmacist will have no problem recognizing that this coverage is being provided through the Express Scripts retail network.  Mail order prescription medication is provided through the Express Scripts pharmacy. Return to Top

  1. I have just been contacted by some company called CuraScript about my medication. I thought our plan used Express Scripts?

The Plan contracts with Express Scripts to use retail pharmacies with which they have agreements and to use the Express Scripts pharmacy for mail order medication.  CuraScript is an Express Scripts subsidiary providing specialty medications if the employee wishes to use them, similar to the mail order pharmacy for people on maintenance medications. Return to Top

  1. What are these enhanced prescription benefits if I have a chronic medical condition?

If you have Asthma, Coronary Artery Disease (CAD), Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) or Diabetes you can reduce your prescription copays for the medicines you take for those conditions to zero ($0.00) for generic medications or to 50% of the normal copays for formulary and brand name medications, whether purchased at a retail pharmacy or through the mail order service.  To get this enhanced benefit you must be “engaged” with a Coordinated Health/Care Nurse Case Manager (you talk on a regular basis, usually once or twice a year or whenever the nurse reaches out to you for an update) about your condition(s).  If you have one of these conditions and you have never talked with a Nurse Case Manager about it, you can call the number on the back of your Plan ID card and ask about the enhanced prescription benefit for chronic conditions. Return to Top