Medical plan
Do I have to participate in Aldine ISD medical coverage?

No. But you should take time to learn about the medical coverage available to you through the Aldine ISD medical plan options as well as any other source available to you, such as your spouse’s medical benefits plan. Compare and consider the cost of coverage for each option. This can help you decide which coverage works best for you and your family.

If you don’t select Aldine ISD medical coverage, you and your eligible family members may enroll for the Discount Rx program. This prescription drug program entitles you to a discount from Express Scripts participating pharmacies and mail service. The discount prescription drug option isn’t insurance. You’re responsible for paying the entire discounted prescription price.

Do I get a member ID card after I enroll for coverage?

When you enroll, you receive a medical/prescription drug ID card that can be used for medical providers and Express Scripts prescriptions.

For more information, call Aetna at 877-224-6857, 8 a.m. to 6 p.m. Central Time, weekdays (except holidays) or Express Scripts at 855-712-1403.

What’s the difference between a copay and coinsurance?

Copay — A copay is a set fee that you pay for certain services and goods, such as prescription drugs.  

Coinsurance — Conisurance is the percentage of expenses for covered services that you pay after you meet your deductible and until you reach your annual coinsurance maximum.  For example, for inpatient hospital care with the Memorial Hermann ACO plan, you pay 20% of the total bill. With the Open Access Select plan, you would pay 30%. 

What’s a primary care physician (PCP)?

A primary care physician is a provider who provides most of your primary and preventive care, and who is available to refer you to specialists if necessary. While there’s no requirement to designate a primary care physician and you can change providers at any time, most people have a primary care physician overseeing their care. While obtaining a referral to see a specialist isn’t necessary, primary care physicians can be a valuable resource in identifying the type of specialist you need to see and providing a list of specialty providers who might work well for you.

What does pre-certification mean?

Pre-certification is the process of obtaining approval before certain health care services or procedures are performed. Pre-certification is required for all in-patient admissions and a number of outpatient services, including high tech radiology procedures, such as MRIs and CT scans. For a full list of services or supplies that require pre-certification or pre-notification, log on to Aetna Navigator or call Aetna at 800-333-4432, weekdays between 8 a.m. and 6 p.m. Central Time. Failure to get pre-certification when required results in a penalty of 50% before the appropriate coinsurance is applied or, in the case of high tech radiology, the procedure is not covered.

Although your provider may contact Aetna for authorization on your behalf, you’re ultimately responsible for making sure Aetna’s approval is obtained or the care or service you receive may not be covered.

If you’re unable to obtain pre-certification due to an emergency, report the emergency to Aetna as soon as possible to comply with this requirement.

What does "usual, customary and reasonable" mean?

Usual, customary and reasonable (UCR) limits are based on prevailing costs of services or supplies for the geographic area in which the services or supplies are provided. In-network services are contracted and cannot exceed UCR limits. If you use an out-of-network facility for emergency care, the plan pays its percentage of coverage up to the UCR amount, not the facility’s actual charges. You’re responsible for paying the difference between the covered amount and the amount the facility charges.

Do I pay anything for prescription drugs after the copay?

Yes, if you’re covered by the Memorial Hermann ACO, there’s a $75 annual prescription drug deductible that’s separate from your medical plan deductible. Once you meet the $75 deductible for a covered individual, all you pay is your copay and the plan pays any remaining amount above your copay.

If you're covered by the Open Access Select option, you have a $250 individual/$500 family annual prescription drug deductible that's separate from your medical plan deductible. Once you meet the prescription drug deductible, you pay 30% of the cost of covered prescriptions.

What’s the preventive care benefit?

You and your covered family members receive 100% coverage with no annual deductible for preventive care expenses.

What’s considered “preventive care”?

Preventive care services help maintain health and prevent disease and include annual physicals, well-woman exams, prostate check ups, immunizations and more. If you’re not sure what’s considered preventive care, call Aetna customer service at 877-224-6857, available 8 a.m. to 6 p.m. Central Time, weekdays (except holidays).

If I meet the annual out-of-pocket maximum, do I have to pay more if I need additional services?

Generally, no. Once you meet the out-of-pocket maximum amount, the plan pays 100% of all covered expenses you have for the rest of the year. This doesn’t include copays or non-covered expenses such as amounts over the usual, customary and reasonable (UCR) limits for emergency care.

Can I have Aldine ISD medical coverage and Medicare?

Yes. If you have Aldine ISD medical coverage as an active employee, that coverage is primary and Medicare is secondary. For more information, please contact Medicare.

What can I do if my medical claim is denied?

Call Aetna at 877-224-6857 8 a.m. to 6 p.m. Central Time, weekdays (except holidays)

Where can I get medical plan provider directories?

All medical plan options offer network care through Aetna. You may request printed directories by calling Aetna; however, the most up-to-date information about providers can be found by logging on to Aetna Navigator and checking DocFind or by contacting Aetna member services at 877-224-6857 8 a.m. to 6 p.m. Central Time, weekdays (except holidays).

Remember that directory information is for reference only. Always verify the provider's address, phone number, specialty and any other information before making an appointment.

Is pregnancy a pre-existing condition under the Aetna options?

No. Pregnancy isn’t considered a pre-existing limitation for purposes of the plan.

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For any benefits question or concern, including 24/7 Nurse Line access, one call does it all.
Call us at 866-284-AISD (2473)