Aetna's Choice POS II - Open Access Plans, are intended to meet the needs of the majority of our population by providing nationwide access in most areas and predetermined copayments for those services. The Aetna Choice POS II Plans does not require you to select a network primary care physician (PCP) although selecting a PCP is encouraged. Members have access to all in-network providers without having to obtain a referral. Those individuals choosing non-preferred providers may utilize the out of network benefits and will be responsible for paying applicable deductables and coinsurance.

Beginning March 1, 2005, County employees will have selected either the Base Plan option or the Base Plus Plan option. Both plans are Aetna Choice POS II Plans so employees and their dependants can continue to self refer to any Aetna specialist for services. While the Base Plus Plan option requires copayments for specific services, if you have enrolled in the Base Plan you may encounter deductables and coinsurance when utilizing some services.

The Harris County medical plans are offered through Aetna and afford you the opportunity to choose any doctor or other health care provider. Whether you utilize in-network or out-of-network benefits depends on where and with whom you receive your care. Neither plan requires a PCP selection or referrals for specialist visits.

Employees are given the opportunity annually to choose between the Base Plan OR Base Plus Plan. These plans consist of a point-of-enrollment option for employees with a “Base” level of benefits at no cost for employee only coverage. In addition, the County will pay 50% of the incremental cost of dependent coverage. The “Base” plan offers a high level of affordable access to basic health and preventative services as well as protection to pay for high cost hospital and surgical expenses while containing premium cost increases for both the County and employees. While many routine services on the “Base” plan only require a copayment; some inpatient and outpatient services are subject to an annual deductible and coinsurance when utilizing a provider in-network and/or out-of-network.
 
The second option provided to employees is a “Plus” plan that allows employees to pay a higher contribution to receive a higher level of benefits. The County will pay 50% of the incremental cost of dependent coverage. The “Plus” plan has no deductibles or coinsurance when utilizing in-network providers, though out-of-network providers will be subject to deductibles on both the “Base” and “Plus” plans.

Both plans contain the same prescription drug benefit, which will encourage cost effective utilization of these benefits and provides potential savings to both employees and the County.

Because time is of the essence, technology and convenience are the key factors in conducting business. Plan participants may log on to http://www.aetna.com/ to check claims payment status, eligibility, order an ID card, Price A Procedure, Price A Drug, print your Explanation of Benefits (EOB) statements, check out the Clinical Policy Bulletins, refill mail order prescriptions, query for medical information or just search for a provider anywhere in the country. Utilizing the Aetna tools enables you to get the most value out of your plan and save time!

Medical Plan & Pharmacy Changes effective March 1, 2007:

• Increased Emergency Room Copay from $125 to $150 - Both Plans (pages 11 & 12 of your Resource Guide)
• Base Plan - change Out of Network Coinsurance from 70% to 60% (pages 8 & 11 of your Resource Guide)
• Base Plus Plan - change Out of Network Coinsurance from 80% to 70% (pages 10 & 12 of your Resource Guide)
• Therapeutic RX Management for Proton Pump Inhibitors (PPI) (page 5 of your Resource Guide)
• Aetna Specialty RX Program after Second Refill at a Retail Pharmacy (pages 6 & 9 of your Resource Guide)
• Aetna RX Check (page 5 of your Resource Guide)
• Mandatory Mail Order has been delayed until further notice

Harris County employees have the option of choosing either a DHMO Plan or Indemnity Plan for their dental care.  You must choose one plan at the beginning of each plan year and no plan changes can be made until the next open enrollment.

• Review the plans and decide which fits your needs best: DHMO or the Dental Indemnity Plan.
• If you select the DHMO Plan, choose a participating dentist from the directory of dental providers.
• Remember that the dependents you enrolled in the medical plan will be covered under the dental as well. Each family member may choose a different provider.
• If you select the Indemnity Plan you must file a claim for reimbursement.

Dental DHMO
First, you must select a dentist who is affiliated with SafeGuard. A list of these dentists can be obtained from your department’s Benefits Coordinator, or online at http://www.safeguard.net/  If you need specialty care, specialists are available, including orthodontists.

Standard covered services with little or no copayment:

• Examinations and x-rays
• Two basic cleanings each year
• Pulp vitality tests
• Partial or denture adjustments
• Orthodontic consultations
• Fluoride treatment
• Diagnostic consultations
• Crowns recemented

Services that are NOT COVERED:

• Services of dentists not associated with this Plan
• Hospitalization for any dental procedure
• Experimental procedures
• Prescription and non-prescription drugs
• Oral surgery to set a fracture or dislocation
• Services for conditions already covered under Workers’ Compensation
• Implants and implant-related products
• Temporomandibular Joint (TMJ) Dysfunction (medical)
• Full mouth reconstruction

A full Schedule of Benefits with co-payments and Exclusions & Limitations are available at http://www.safeguard.net/.

Dental Indemnity Plan
The second plan is an Indemnity Plan available through SafeGuard that gives you the freedom to select any dentist or specialty dentist for any appointment you schedule. In addition, you can choose a different dentist for each member of your family.

If you decide the indemnity plan is right for you, there is no need to “pre-register” with a dental care provider - you can receive treatment from any dentist. When choosing a dentist, remember that if you choose to receive care from a contracted SafeGuard dentist, you could save on your out-of-pocket costs. Contracted dentists have agreed to accept the negotiated fee as payment in full with no balance billing.

Your Costs
Payment of claims is based on a Maximum Allowable Charge (MAC). The Maximum Allowable Charge is set by SafeGuard and based on negotiated rates with contracted dentists. This MAC is the most that SafeGuard will pay for a particular dental procedure under the plan.

A Summary of Benefits includes the information on how payment is calculated for your plan and is included in your enrollment kit along with the plan Exclusions & Limitations. If, after reviewing the plan documents, you have any questions, Member Services Representatives will be happy to help you at 800.880.1800, 8am – 8pm, CST, Monday—Friday.

 

Dental HMO - SGC1011-TX	Dental Indemnity – SHCN420
No calendar year maximums; no yearly deductibles	$1,750 calendar year maximum; $50 yearly individual deductible ($150 for family)
Basic care provided by contracted general dentists selected at enrollment.  Members may change their designated provider by contacting SafeGuard customer service.   Requested changes will be effective the 1st of the following month.	You may receive care from any licensed dentist; contracted dentists have agreed to accept negotiated fees as payment in full.
Each family member may select a different general dentist (remember to include the facility number when enrolling).	Non-contracted dentists could “balance bill” which may result in higher out-of-pocket costs (see the Summary of Benefits for more information).
Covered procedures and co-payments are listed on the Schedule of Benefits.	Claims are paid based on the percentages listed on the Summary of Benefits.
When specialty care is required, your selected general dentist can refer with no need to contact SafeGuard for approval.	If you require specialty care, you may see any specialty care dentist you choose. Or receive care from a contracted dentist, which may save you on your expenses.
No waiting periods.	6 month wait on endodontic procedures & all Major services (Additional waiting period of 6 months for endodontia and major services for new employees and newly added dependents of current employees).
Adult & child orthodontics included.	Orthodontia is not a covered benefit.
No claim forms required.	Claim forms may be required.

CUSTOMER SERVICE

SafeGuard has two sources for assistance 24 hours a day, 7 days a week. You can call 800.880.1800 and follow the prompts for IVR (Interactive Voice Recognition) assistance or utilize online services.

SafeGuard has created a website specifically for County employees.  Logon at http://www.safeguard.net/ and select “Group Specific Sites” from the homepage.  Benefit summaries, plan documents and answers to frequently asked questions are included along with much more.  You can also learn more about SafeGuard, review educational information for adults and children, and access the online directory to find the most current provider listings.  

The customized Harris County website was designed to help you get the most from your dental benefits program.  You have instant access to…

• Change providers (Dental HMO)
  
• Email Member Services
  
• Find a new provider
  
• Nominate a provider
  
• Print an ID card
  
• Print your plan

Harris County Vision Care Program is offered through Spectera Inc. In accordance with the vision care schedule of benefits, you have the choice of using the PPO Plan or receiving the Indemnity Plan reimbursement allowance. Remember, vision coverage is provided automatically for you and each dependent you enroll in the medical plan.

With the PPO Plan, you use participating providers, pay lower out-of-pocket expenses and receive a higher level of benefit. The Indemnity Plan allows you to visit the providers of your choice in exchange for higher out-of-pocket costs.

HOW THE VISION CARE PROGRAM WORKS:

Each time you need vision care, you may seek care through the PPO Plan: Select a Spectera participating provider by calling the provider locator at (800) 839-3242, or from www spectera com.

• When you make your appointment, identify yourself as a Harris County Spectera Vision Plan member.
• Examination: $10 copay; once every 12 months. A vision examination is provided by a network optometrist or ophthalmologist.
• Standard frames and lenses are covered at 100% after $25 copay.
• Non-selection frames are available for wholesale cost plus a $10 handling fee.
• Standard contact lenses are covered at 100% after $25 copay in lieu of glasses.

Covered Services

Highlights of your vision care benefits are shown below. For the complete schedule of benefits reference the Vision Plan Benefit Certificate of Coverage.

Service/Product	PPO Plan	Indemnity Reimbursement Plan
Complete Visual Exam*	$10 copay	Up to $40
Materials— Entire purchase of eyeglasses, including lenses & frames OR contacts in lieu of eyeglasses	$25 Materials Copay for eyeglasses or contact lenses	Up to $45
Lenses
Single Vision Lenses*	100% after $25 Materials Copay	Up to $40
Bifocal Vision Lenses*	100% after $25 Materials Copay	Up to $60
Lined Trifocal Vision Lenses*	100% after $25 Materials Copay	Up to $80
Contact Lenses
Elective