This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory. You have a choice of enrollment in a High Option, a Standard Option, or a High Deductible Health Plan (HDHP) Option.
OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Aetna holds the following accreditations: National Committee for Quality Assurance and/or the local plans and vendors that support Aetna hold accreditation from the National Committee for Quality Assurance. To learn more about this plan’s accreditation(s), please visit the following website:
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.
General features of our High and Standard Options
- The deductible for our High and Standard Option plans is:
- High Option: $50 for Self Only or $100 for Self Plus One or Self and Family coverage
- Standard Option: $100 for Self Only or $200 for Self Plus One or Self and Family coverage.
Once an individual meets the Self Only deductible under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.
- Most services provided by physicians and other health care professionals, including physician services that are provided while you are in a hospital, may be subject to a copayment or coinsurance.
- Comprehensive dental coverage is included in our High Option.
- The Standard Option does not include dental coverage (except for dental services that are necessary as a result of an accidental injury to sound, natural teeth).
We protect you against catastrophic out-of-pocket expenses for covered services. Your annual out-of-pocket expenses for covered services, including deductibles and copayments, cannot exceed:
- High Option: $5,500 for Self Only or $11,000 for Self Plus One or Self and Family coverage.
- Standard Option: $6,000 for Self Only or $12,000 for Self Plus One or Self and Family coverage.
Once an individual meets the Self Only out-of-pocket maximum under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical expenses at 100%. The remaining balance of the Self Plus One or Self and Family out-of-pocket maximum can be satisfied by one or more family members.
We have Open Access benefits
Our HMO offers Open Access benefits. This means you can receive covered services from a participating provider without a required referral from your primary care physician or by another participating provider in the network.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies). We compensate contracted providers by either discount fee-for-service fee schedules or capitation agreements. It is your responsibility to verify that the provider you use is a Plan provider. Except for emergency and out-of-area urgent care, we will not pay for care or services from non-Plan providers or facilities unless it has been authorized by us. If you use a non-Plan provider or facility without authorization from us, you may be responsible for all charges.
You do not have to select a Primary Care Physician (PCP), you may self-refer to Plan specialists. However, we recommend that you select a PCP to coordinate all of your medical care. A PCP should practice one of the following disciplines: General Practice, Family Medicine, Internal Medicine, Obstetrics/Gynecology (OB/GYN), or Pediatrics. You are responsible for making sure that a provider is a Plan provider. Should you have any questions, please contact our Customer Service Department at 800-537-9384, or visit our website at www.aetnafeds.com.
General features of our High Deductible Health Plan (HDHP)
An HDHP is a health plan product that provides traditional health care coverage and a tax-advantaged way to help you build savings for future medical needs. An HDHP with an HSA or HRA is designed to give greater flexibility and discretion over how you use your health care benefits. As an informed consumer, you decide how to utilize your plan coverage with a high deductible and out-of-pocket expenses limited by catastrophic protection. And you decide how to spend the dollars in your HSA or HRA. You have:
- An HSA in which the Plan will automatically deposit $62.50 per month/Self Only or $125.00 per month/Self Plus One or $125.00 per month/Self and Family.
- The ability to make voluntary contributions to your HSA of up to $2,850/Self Only or $5,700/Self Plus One or $5,700/Self and Family per year. If you are age 55 or older, you may also make a catch-up contribution of up to $1,000 for 2021.
You may consider:
- Using the most cost effective provider.
- Actively pursuing a healthier lifestyle and utilizing your preventive care benefit.
- Becoming an informed health care consumer so you can be more involved in the treatment of any medical condition or chronic illness.
The type and extent of covered services, and the amount we allow, may be different from other plans. Read our brochure carefully to understand the benefits and features of this HDHP. The IRS website at https://www.treasury.gov/resource-center/faqs/Taxes/Pages/Health-Savings-Accounts.aspx has additional information about HDHPs.
Preventive care services
Preventive care services are generally covered with no cost-sharing and are not subject to copayments, deductibles or annual limits when received from a network provider.
Annual deductible
The annual deductible of $1,400 for Self Only, $2,800 for Self Plus One or $2,800 for Self and Family must be met before Plan benefits are paid for care other than preventive care services. Once an individual meets a deductible of $2,800 under the Self Plus One or Self and Family enrollment, they will then be covered under Plan benefits. The remaining balance of the Self Plus One or Self and Family deductible can be satisfied by one or more family members.
Health Savings Account (HSA)
You are eligible for an HSA if you are enrolled in an HDHP, not covered by any other health plan that is not an HDHP (including a spouse's health plan, excluding specific injury insurance and accident, disability, dental care, vision care, or long-term coverage), not enrolled in Medicare, not received VA (except for veterans with a service-connected disability), or Indian Health Service (IHS) benefits within the last three months, and are not claimed as a dependent on someone else's tax return.
- You may use the money in your HSA to pay all or a portion of the annual deductible, copayments, coinsurance, or other out-of-pocket costs that meet the IRS definition of a qualified medical expense.
- Distributions from your HSA are tax-free for qualified medical expenses for you, your spouse, and your dependents, even if they are not covered by a HDHP.
- You may withdraw money from your HSA for items other than qualified medical expenses, but it will be subject to income tax and, if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.
- For each month that you are enrolled in an HDHP and eligible for an HSA, the HDHP will pass through (contribute) a portion of the health plan premium to your HSA. In addition, you (the account holder) may contribute your own money to your HSA up to an allowable amount determined by IRS rules. In addition, your HSA dollars earn tax-free interest.
- You may allow the contributions in your HSA to grow over time, like a savings account. The HSA is portable - you may take the HSA with you if you leave the Federal government or switch to another plan.
Health Reimbursement Arrangement (HRA)
If you are not eligible for an HSA, or become ineligible to continue an HSA, you are eligible for a Health Reimbursement Arrangement (HRA). Although an HRA is similar to an HSA, there are major differences.
- An HRA does not earn interest.
- An HRA is not portable if you leave the Federal government or switch to another plan.
You must notify us that you are ineligible for an HSA. If we determine that you are ineligible for an HSA, we will notify you by letter and provide an HRA for you.
Catastrophic protection
We protect you against catastrophic out-of-pocket expenses for covered services. Your annual out-of-pocket expenses for covered services, including deductibles and copayments, and coinsurance cannot exceed $6,000 for Self only enrollment, and $12,000 for a Self Plus One or Self and Family enrollment. Once an individual meets the Self Only out-of-pocket maximum under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical expenses at 100%. The remaining balance of the Self Plus One or Self and Family out-of-pocket maximum can be satisfied by one or more family members. The out-of-pocket limit for this Plan may differ from the IRS limit, but cannot exceed that amount.
Health education resources and accounts management tools
We have online, interactive health and benefits information tools to help you make more informed health decisions (see HDHP Section 5(i).
Your member website gives you direct access to:
- Personal Health Record that provides you with online access to your personal health information including health care providers, drug prescriptions, medical tests, individual personalized messages, alerts and a detailed health history that can be shared with your physicians.
- Care and Costs tools that compare provider fees, the cost of brand-name drugs vs. their generic equivalents, and the costs for services such as routine physicals, emergency room visits, lab tests, X-rays, MRIs, etc.
- Real-time, out-of-pocket estimates for medical expenses based on your Altius health plan. You can compare the cost of doctors and facilities before you make an appointment, helping you budget for and manage health care expenses.
- A hospital comparison tool that allows you to see how hospitals in your area rank on measures important to your care.
- Our online provider directory.
- Online customer service that allows you to request member ID cards, send secure messages to Member Services, and more.
- Healthwise® Knowledgebase where you get information on thousands of health-related topics to help you make better decisions about your health care and treatment
For more information about these and other available tools and resources, please see HDHP Section 5(i).
Your rights and responsibilities
OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers. OPM's FEHB website (www.opm.gov/healthcare-insurance) lists the specific types of information that we must make available to you. Some of the required information is listed below.
- Altius Health Plan is a licensed Health Maintenance Organization in Utah, Idaho and Wyoming.
- Altius Health Plan has been in existence for more than 30 years.
- Altius Health Plan is a for-profit, Aetna Company.
You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our website, www.aetnafeds.com. You can also contact us to request that we mail a copy to you.
If you want more information about us, call 800-537-9384, or write to Aetna at P.O. Box 550, Blue Bell, PA 19422-0550. You may also visit our website at www.aetnafeds.com.
By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our Aetna website at www.aetnafeds.com to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.
Your medical and claims records are confidential
We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescriptions drug utilization) to any of our treating physicians or dispensing pharmacies.
Medical Necessity
"Medical necessity" means that the service or supply is provided by a physician or other health care provider exercising prudent clinical judgment for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that provision of the service or supply is:
- In accordance with generally accepted standards of medical practice; and,
- Clinically appropriate in accordance with generally accepted standards of medical practice in terms of type, frequency, extent, site and duration, and considered effective for the illness, injury or disease; and,
- Not primarily for the convenience of you, or for the physician or other health care provider; and,
- Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the illness, injury or disease.
For these purposes, "generally accepted standards of medical practice," means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, or otherwise consistent with physician specialty society recommendations and the views of physicians practicing in relevant clinical areas and any other relevant factors.
Only medical directors make decisions denying coverage for services for reasons of medical necessity. Coverage denial letters for such decisions delineate any unmet criteria, standards and guidelines, and inform the provider and member of the appeal process.
All benefits will be covered in accordance with the guidelines determined by Altius.
Direct Access Ob/Gyn Program
This program allows female members to visit any participating gynecologist for a routine well-woman exam, including a Pap smear, one visit per calendar year. The program also allows female members to visit any participating gynecologist for gynecologic problems. Gynecologists may also refer a woman directly to other participating providers for specialized covered gynecologic services. All health plan preauthorization and coordination requirements continue to apply. If your Ob/Gyn is part of an Independent Practice Association (IPA), a Physician Medical Group (PMG), an Integrated Delivery System (IDS) or a similar organization, your care must be coordinated through the IPA, the PMG, the IDS, or similar organization and the organization may have different referral policies.
Mental Health/Substance Use
Behavioral health services (e.g. treatment or care for mental disease or illness, alcohol abuse and/or substance use) are managed by Aetna Behavioral Health. We also make initial coverage determinations and coordinate referrals, if required; any behavioral health care referrals will generally be made to providers affiliated with the organization, unless your needs for covered services extend beyond the capability of these providers. As with other coverage determinations, you may appeal behavioral health care coverage decisions in accordance with the terms of your health plan.
Ongoing Reviews
We conduct ongoing reviews of those services and supplies which are recommended or provided by health professionals to determine whether such services and supplies are covered benefits under this Plan. If we determine that the recommended services and supplies are not covered benefits, you will be notified. If you wish to appeal such determination, you may then contact us to seek a review of the determination.
Authorization
Certain services and supplies under this Plan may require authorization by us to determine if they are covered benefits under this Plan. See section 3, "You need prior plan approval for certain services."
Patient Management
We have developed a patient management program to assist in determining what health care services are covered and payable under the health plan and the extent of such coverage and payment. The program assists members in receiving appropriate health care and maximizing coverage for those health care services.
Where such use is appropriate, our utilization review/patient management staff uses nationally recognized guidelines and resources, such as Milliman Care Guidelines© and InterQual® ISD criteria, to guide the precertification, concurrent review and retrospective review processes. To the extent certain utilization review/patient management functions are delegated to integrated delivery systems, independent practice associations or other provider groups ("Delegates"), such Delegates utilize criteria that they deem appropriate.
Precertification
Precertification is the process of collecting information prior to inpatient admissions and performance of selected ambulatory procedures and services. The process permits advance eligibility verification, determination of coverage, and communication with the physician and/or you. It also allows Altius to coordinate your transition from the inpatient setting to the next level of care (discharge planning), or to register you for specialized programs like disease management, case management, or our prenatal program. In some instances, precertification is used to inform physicians, members and other health care providers about cost-effective programs and alternative therapies and treatments.
Certain health care services, such as hospitalization or outpatient surgery, require precertification with Altius to ensure coverage for those services. When you are to obtain services requiring precertification through a participating provider, this provider should precertify those services prior to treatment.
Concurrent Review
The concurrent review process assesses the necessity for continued stay, level of care, and quality of care for members receiving inpatient services. All inpatient services extending beyond the initial certification period will require concurrent review.
Discharge Planning
Discharge planning may be initiated at any stage of the patient management process and begins immediately upon identification of post-discharge needs during precertification or concurrent review. The discharge plan may include initiation of a variety of services/benefits to be utilized by you upon discharge from an inpatient stay.
Retrospective Record Review
The purpose of retrospective record review is to retrospectively analyze potential quality and utilization issues, initiate appropriate follow-up action based on quality or utilization issues, and review all appeals of inpatient concurrent review decisions for coverage and payment of health care services. Our effort to manage the services provided to you includes the retrospective review of claims submitted for payment, and of medical records submitted for potential quality and utilization concerns.
Member Services
Representatives from Member Services are trained to answer your questions and to assist you in using the Altius Health Plan properly and efficiently. After you receive your ID card, you can call the Member Services toll-free number on the card when you need to:
- Ask questions about benefits and coverage.
- Notify us of changes in your name, address or phone number.
- Change your primary care physician or office.
- Obtain information about how to file a grievance or an appeal
Privacy Notice
How we guard your privacy - We’re committed to keeping your personal information safe
What personal information is — and what it isn’t - By “personal information,” we mean that which can identify you. It can include financial and health information. It doesn’t include what the public can easily see. For example, anyone can look at what your plan covers.
How we get information about you - We get information about you from many sources, including from you. But we also get information from your employer, other insurers, or health care providers like doctors.
When information is wrong - Do you think there’s something wrong or missing in your personal information? You can ask us to change it. The law says we must do this in a timely way. If we disagree with your change, you can file an appeal. Information on how to file an appeal is on our member website. Or you can call the toll-free number on your ID card.
How we use this information - When the law allows us, we use your personal information both inside and outside our company. The law says we don’t need to get your OK when we do.
We may use it for your health care or use it to run our plans. We also may use your information when we pay claims or work with other insurers to pay claims. We may use it to make plan decisions, to do audits, or to study the quality of our work.
This means we may share your info with doctors, dentists, pharmacies, hospitals or other caregivers. We also may share it with other insurers, vendors, government offices, or third-party administrators. But by law, all these parties must keep your information private.
When we need your permission - There are times when we do need your permission to disclose personal information.
This is explained in our Notice of Privacy Practices, which took effect October 9, 2018. This notice clarifies how we use or disclose your Protected Health Information (PHI):
- For workers’ compensation purposes
- As required by law
- About people who have died
- For organ donation
- To fulfill our obligations for individual access and HIPAA compliance and enforcement
To get a copy of this notice, just visit our member website. Or call the toll-free number on your ID card.
Service Area
To enroll in this Plan, you must live in or work in our service area. This is where our providers practice. Our service area is:
Utah - The counties of Beaver, Box Elder, Cache, Carbon, Daggett, Davis, Duchesne, Garfield, Iron, Juab, Kane, Millard, Morgan, Piute, Rich, Salt Lake, San Juan, Sanpete, Sevier, Summit, Tooele, Uintah, Utah, Wasatch, Washington, Weber and Wayne.
Portions of Emery and Grand as defined by the following zip codes:
Emery - 84513, 84516, 84518, 84521, 84522, 84523, 84528, 84537
Grand - 84515, 84532
Idaho - The counties of Ada, Adams, Bannock, Bear Lake, Bingham, Blaine, Boise, Bonneville, Camas, Canyon, Caribou, Cassia, Clark, Custer, Elmore, Franklin, Fremont, Gem, Gooding, Jefferson, Jerome, Lincoln, Madison, Minidoka, Oneida, Owyhee, Payette, Power, Teton, Twin Falls, Valley and Washington.
Wyoming - The counties of Lincoln, Sweetwater, and Uinta
You must receive your care from providers who contract with us. If you receive care outside our service area, we will pay only for urgent or emergency care benefits. We will not pay for any other health care services out of our service area unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), they will be able to access full HMO benefits if they reside in any Aetna HMO service area by selecting a PCP in that service area. If not, you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.
