General Medical Questions
Your plan (Open POS II) is a Preferred Provider plan, which means you can go to any doctor or specialist, in or out of the network, without a referral from your primary doctor. You will have access to a broad national provider network, be eligible for discount programs, have access to helpful online tools, and a dedicated member services number to call with any questions on your health plan.
You can learn more about your health plan on the Medical Plan Info page.
If you have specific questions about your benefits or how the plan works, call Member Services toll free at 1-888-236-6249.
The network has about 1.2 million health care professionals and more than 5,700 hospitals nationwide¹.
To search for doctors, hospitals, and other health care providers in your area, visit DocFind®, our online provider directory.
DocFind is more than just a list of doctors’ names and addresses. It also includes information about:
- Where the physician attended medical school
- Board certification status
- Language spoken
- Driving directions to their office
You can also call Member Services toll-free at 1-888-236-6249 and speak to a representative who can answer your questions about participating providers.
¹Information as of August 21, 2018.
No, the plan does not require that you select a PCP. However, it is important to build a connection with your primary care physician (PCP), as he or she is your health care home base. Your PCP provides routine preventive care and treats illnesses and injuries.
Over time, your PCP gets to know you and your health care needs, conditions and challenges. And your PCP can coordinate services, make recommendations, and share information with other health care providers. It’s a relationship that benefits you in sickness and in good health.
No, the plan does not require a referral for visits to a specialist. Your plan is a Preferred Provider plan, which means you can go to any doctor without ever needing a referral.
Precertification or preauthorization is required for certain diagnostic and imaging services. Aetna/Innovation Health contracts with eviCore to provide this service. The following are some of the tests, procedures, and services that require review by eviCore: diagnostic cardiology, sleep studies management, cardiac rhythm implant devices, and radiation oncology therapy.
Yes. Through Teladoc, members have 24/7 access to a national network of U.S. board-certified doctors through phone or online video consultation. Members are able to reach a doctor from anywhere - home, work, or even while traveling! Teladoc physicians can diagnose non-emergency medical problems - such as respiratory infections, ear infections, allergies, colds and flus - recommend treatment, and even call in a prescription to your pharmacy of choice!
Teladoc is available 24/7* at 1-855-TELADOC(835-2362). For each consultation, your cost of service is equal to or less than the cost of an office visit, subject to deductible.
*Teladoc is subject to state regulations and may not be available in all states.
Innovation Health is a unique partnership between two industry leaders: Aetna and Inova. Aetna is one of the nation’s leading health insurance companies serving approximately 22.1 million medical members¹. Inova is a nationally recognized not-for-profit health care system serving more than two million people. Together, they have created Innovation Health, a national health care plan that includes about 1.2 million heath care professionals and more than 5,700 hospitals1.
¹ Information as of June 30, 2018.
Yes. The member website is your connection to all your active plan information and links to resources and tools. Once you receive your ID card, visit your member website to register. After you are enrolled and registered for your member website, you can log in anytime — day or night — to:
- Look up plan information
- View information on your covered dependents
- Find network doctors, dentists, hospitals, vision providers and labs faster and easier with the DocFind® search tool
- Take a health assessment and get started on the road to wellness
- Check on symptoms and get possible causes
- Access cost of care and hospital comparison tools
- Download forms
- Order a replacement ID card
- Send an e-mail to Member Services with your questions
- Review your explanation of benefits (EOB) for recent claim
Learn more about using your member website.
The Health Assessment (HA) is an optional questionnaire related to different aspects of general health and well-being that is easy to complete in about 15-20 minutes. It provides a snapshot of your current health status and includes a wellness score so you can become familiar with potential health risks and receive strategies to help reduce them. Your individualized health report may also include information on how to obtain health coaching and/or receive other health or wellness programs that are offered through AIH.
The HA is strictly confidential and only AIH receives your information. Your health related information is not shared with FCPS in compliance with state and federal privacy laws.
FCPS subscribers (the employee enrolled as the primary cardholder) participating in the Aetna/Innovation (AIH) health insurance plan will have an opportunity to earn a $100 wellness incentive by completing their online health assessment (HA) between January 1, 2019 and December 31, 2019.
The incentive is only available to subscribers in 2019.
For more details on how to obtain your wellness incentive and directions on how to complete your HA go to the FAQs.
If you're ready to take your HA, be sure to read the step-by-step instructions before you begin.
Your privacy is important to us. Our policies protect your personal information from unlawful use. By personal information, we mean information that can identify you as a person, as well as your financial and health information.
Yes, there are two, free resources that can help you.
Nurse Concierge — The Nurse Concierge is a dedicated specialist who will work to help you get the right care at the right time. Your nurse concierge is paying attention to signs that show you could be having a problem, and will access a team of health care professionals should you have a complex health condition. If you have an issue, we call you right away to help you get what you need. Or you can call us Monday to Friday 9:00 am - 4:30pm at 571-421-2810.
Learn more about the Nurse Concierge.
- Aetna Health ConnectionsSM disease management program — Whether you’ve been working with your doctor to manage a condition, or you just received a diagnosis, this program can help you follow your treatment plan. There are online programs, group coaching and one-on-one nurse support available to do what’s best for you. This program supports more than 35 health conditions, including diabetes, heart disease, asthma and low back pain. It’s likely the program can help with your condition, too. You may get a call or letter from us to join the program. Or, you can call 1-866-269-4500 to learn more or sign up.
Learn more about the disease management program.
Provider Network Questions
Your plan network is a broad, national network that includes about 1.2 million health care professionals and more than 5,700 hospitals¹.
¹Information as of August 21, 2018.
There are three main advantages to using network doctors: quality, convenience, and savings.
Quality – Doctors who are admitted to the network have met our tough standards for quality.
Convenience – Your network doctor will file claims for you. Your network doctor will also get any plan permissions (called precertification requirements) for you.
Savings – We have negotiated contracts with our network providers to determine how much they will charge you for covered services. That amount is less than what they would charge you if they were not in our network. Network doctors also agree to not bill you for any amount over their contract rate. All you have to pay is your coinsurance or copayments, along with any deductible.
Remember, you have out-of-network coverage, though you generally pay more for health care. If your doctor does not participate in the network, you may encourage your doctor to join our network. Here’s how you or your doctor can start the process:
- To nominate your doctor to join our network, just call Member Services at 1-888-236-6249.
- If your doctor is interested in joining the network, have them call 1-800-353-1232.
You have access to the Member Payment Estimator, where you can search for and compare actual costs for common procedures, treatments and doctors' services. Your deductible and coinsurance are factored in, so you get a real-time cost based on your current year's plan.* Like other helpful tools, you’ll find it on your secure member website. Register or log in to your member website.
If you want help using the Member Payment Estimator or any of the tools available on your member website, watch this video.
*Estimated costs not available in all markets. The tool provides an estimate of what would be owed for a particular service based on the plan at that very point in time.
While our network is large, it’s possible that you may want to seek care from a provider who doesn’t participate in the network. Please note that you pay more for care received outside of the network. Also, if the doctor is not in the network, you may have to file your own claims and get any necessary permission (called precertification requirements) for certain services.
- File a claim – You can download and print claim forms and later track your claims from your member website. No Internet Access? Member Services can help with that. Just call 1-888-236-6249 for assistance.
- Request precertification – To begin the process, call the “precertification” phone number shown on your ID card.
Transition of Care Questions
Transition of Care lets new plan entrants continue a course of treatment with an out-of-network doctor for up to 90 days at in-network level of benefits. This gives you time to finish your treatment or transition to an in-network doctor.
In order to qualify for Transition of Care, you must be new to the plan and in an active course of treatment for one of the following situations:
- Second or third trimester of pregnancy, including post-partum care
- Treatment for certain acute and/or chronic conditions such as chemotherapy or kidney dialysis
- Active engagement in an acute inpatient or outpatient rehabilitation program for a condition with a new onset no more than 21 days before the plan’s effective date
- Hospital confinement on the plan’s effective date
- Terminal illness, expected to live six months or less
Examples of conditions that do not qualify for Transition of Care include routine exams, stable chronic conditions such as diabetes or asthma, minor illness such as colds or sore throats, and elective scheduled surgeries.
Contact member services at 1-888-236-6249 for a copy of the Transition of Care form.
Questions About Using the Medical Plan
The amount you pay for covered health services before the plan begins to pay.
There are two types of deductible:
- Individual: The individual deductible applies separately to each covered person in the family. When a person’s deductible expenses reach the individual deductible amount, the person’s deductible is met for that calendar year. The Plan then starts to pay benefits for that person at the appropriate coinsurance percentage.
- Family: The family deductible applies to the family as a group. When the combined deductible expenses of all covered family members reach the family deductible, the family deductible is met for that calendar year. The Plan then begins to pay benefits for all covered family members at the appropriate coinsurance percentage.
Example: For a family of five, each member has an in-network individual deductible of $250, while the family as a whole must meet the family deductible of $500. If each member of the family meets a deductible level of $100, then they have met their family deductible of $500. The plan will then start to pay according to the schedule of benefits for the remainder of the calendar year, depending on the in-network service.
Please refer to the 2019 Summary of Benefits for more details.
Your share of the costs of a covered health care service, calculated as a percent of the allowed amount. The plan pays the rest of the allowed amount. Coinsurance is in addition to deductibles.
A fixed amount you pay for covered health care services. The amount can vary by the type of covered health care service (i.e. Primary Care vs. Specialist). Deductibles apply to most services before you pay the copayment.
Doctors who participate in our network will precertify services for you. If you go outside the network, you will have to do this yourself. If you go outside the network and you don’t precertify services, you will have to pay for all or a larger share of the cost for the service. Even with precertification, you will usually pay more when you use out-of-network doctors. To begin the process when using an out-of-network doctor, call Member Services toll-free at 1-877-973-3238. This number can also be found on your ID card. You must get the precertification before you receive the care.
You pay a flat amount, called a “copay,” after an in-network deductible, for in-network office visits. For more details, please refer to the Medical Summary of Benefits and Coverage on the Medical Plan Documents page.
Preventive care for checkups, screenings, vaccines, prenatal care and more¹ will be covered at 100% when provided in-network.
¹A full list of preventive services is available at https://www.healthcare.gov/what-are-my-preventive-care-benefits/.
In compliance with the Affordable Care Act, FCPS medical plans cover most preventive care services at 100% when using an in-network provider. Preventive care services include routine physicals, immunizations and screenings.
The following preventive care services are covered for adults without cost sharing when using an in-network provider:
- Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol Misuse screening and counseling
- Aspirin use to prevent cardiovascular disease for men and women of certain ages
- Blood Pressure screening for all adults
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal Cancer screening for adults over 50
- Depression screening for adults
- Diabetes (Type 2) screening for adults with high blood pressure
- Diet counseling for adults at higher risk for chronic disease
- HIV screening for everyone ages 15 to 65, and other ages at increased risk
- Immunization vaccines for adults--doses, recommended ages, and recommended populations vary. Full list of services.
- Obesity screening and counseling for all adults
- Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
- Syphilis screening for all adults at higher risk
- Tobacco Use screening for all adults and cessation interventions for tobacco users
In addition, women’s preventive health care services – such as mammograms, screenings for cervical cancer, and other services – are covered with no cost sharing when using an in-network provider. Click here for a list of women's preventive care services. The changes to your medical plan also include coverage for preventive services specific to children, including behavioral assessments, blood pressure and dyslipidemia screening when using an in-network provider. Click here for a list of preventive services that are covered for children.
Please visit the U.S. Department of Health and Human Services website and see a full list of preventives services that are covered for adults, women and children.
Additionally, certain medications, including women’s contraceptives, will be covered at 100%. Several preventive over-the-counter (OTC) products will also be provided at no copay as long as you have a prescription and the recommended criteria are met. Generally, these items are drugs and vitamins recommended for specific age, gender and risk categories. Visit the CVS Caremark site for details.
When you choose to see an out-of-network doctor, hospital or other health care provider, we pay for your care using a “prevailing” or “reasonable and customary” charge obtained from an industry database or a rate based on what Medicare would pay for that service. When you go out-of-network, your doctor may bill you for the difference between his or her actual charge and the amount the plan pays based on what it considers “reasonable.” Doctors in the network have agreed to accept our contracted amount as payment in full and will not bill you for the difference.
The most you pay for covered services during the plan year. The limit includes deductible, coinsurance and copayments. The limit does not include premiums, balance billing amounts or non-network providers and non covered services.
The out-of-pocket maximum does not include:
- Plan premiums
- Amounts you pay for non-covered products or services
- Amounts billed from out-of-network doctors that are above the “reasonable and customary” amount paid by the plan
No. The plan does not place a limit on how much it will pay in expenses during your covered lifetime.
Each time a claim is submitted to the plan for your health care, an Explanation of Benefits (EOB) statement is generated. The EOB includes details about the provider and the amount billed, the amount paid by the plan, and the amount you owe. The statement is not a bill. You will receive any bills for amounts you owe directly from your doctor or health care provider.
If you enrolled in or changed plans during open enrollment, you can expect to receive new member ID cards in late December for coverage effective January 1, 2019. For all other events, you will receive new member ID cards within two weeks of your enrollment. If you do not receive your new ID card, please call Member Services at 1-888-236-6249.
You can also log in to your member website and access a digital ID card or print a paper copy.
You will receive a family ID card. All covered members of your family may use the same card. If your spouse is covered by the plan, you will receive two ID cards. If you need additional ID cards, please contact Member Services at 1-888-236-6249.
You have two ways to do this:
- Online – Log in to your member website. Click on the ID Card link on the top portion of the home page.
- By phone – Call the toll-free Member Services number at 1-888-236-6249, 24 hours a day, 7 days a week. The automated telephone assistant recognizes natural speech, or you can make your selections from your touch-tone keypad. Say, “Order an ID card” and the system will guide you from there. You can also speak live with a Member Services representative during regular business hours.
Yes. CVS Caremark manages the prescription drug plan.
Preauthorization requirements for certain diagnostic and imaging services
Yes. Precertification or preauthorization is required for certain diagnostic services. Aetna/Innovation Health contracts with eviCore to provide this service.
The following are some of the tests, procedures, and services that require review by eviCore: diagnostic cardiology, sleep studies management, cardiac rhythm implant devices, and radiation oncology therapy*.
*Applies to only those tests, procedures and services performed by an in-network provider.
Aetna/Innovation Health contracts with eviCore, an industry leader in medical benefits management. The eviCore clinical team is comprised of more than 1,000 doctors and nurses who use evidence-based guidelines to render precertification services.
1) Your doctor orders a test, procedure or service to diagnose or treat your condition.
2) If that test, procedure, or service* requires precertification, the doctor’s office submits the request to eviCore for clinical review.
3) eviCore performs the review using national medical standards, applying clinical expertise.
4) Your physician and you receive the approval or denial. In most cases, if your doctor submits all necessary clinical information, the request can be approved in a few minutes or less. If you haven’t heard from your physician within 48 hours, you can call member services at 1-888-236-6249 or your physician directly for a status. You will also receive an official letter in 7 to 10 business days via USPS mail.
*Applies to only those tests, procedures and services performed by an in-network provider.
In some cases, a discussion between doctors is necessary to collect further information. If this is the case in your situation, you will receive a denial so that you can immediately take advantage of your appeal rights. Typically your physician will inform you of the status; however you can always contact member services to receive this information. Once a final determination of the appeal has been made, you will receive an official letter in 7 to 10 business days via USPS mail.
In some cases, an alternate recommendation is indicated to your doctor during the review process. If there is a denial, your physician can discuss the case with a eviCore medical director to determine the best course of action. Often, additional medical information is all that is needed. In either case, you have immediate appeal rights.
Contact your physician to determine next steps. Alternatively, you may appeal the decision per the appeals rights provided in the letter from eviCore.