Coinsurance is the percentage of medical expenses that you and the plan share. For example, when using in-network providers, TRS-ActiveCare pays 80 percent of the allowed amount and you pay 20 percent of the allowed amount, after the deductible is met.

A copay is the amount paid at the time of service for certain medical services and prescription drugs. Copays apply to medical out-of-pocket maximums.

In-Network Deductible: This is the amount of in-network covered medical expenses that you pay out-of-pocket each plan year before TRS-ActiveCare begins payment for eligible covered in-network medical and pharmacy expenses. The office visit copays, precertification penalties, charges for out-of-network expenses, charges for services not covered and any payment for charges greater than the plan’s allowable reimbursement do not apply to the in-network deductible.

Out-of-Network Deductible: This is the amount of out-of-network covered medical expenses that you pay out-of-pocket each plan year before TRS-ActiveCare begins payment for eligible covered out-of-network medical and pharmacy expenses. Any expenses paid for in-network covered charges, charges for services not covered and any payment for charges greater than the plan’s allowable reimbursement do not apply to the in-network deductible.

When you seek care from a network provider, your TRS-ActiveCare plan pays a larger portion of your health care costs than it pays for services from a non-network provider. For the TRS-ActiveCare 1-HD and TRS-ActiveCare 2 plans, when you receive care from a non-network provider, you still have coverage but you may pay more of the cost, including any charges over the Aetna-allowed amount.  There is no coverage for non-network care under the TRS-ActiveCare Select plan (except for true emergency care services).

If care is not available from a network provider as determined by Aetna, and Aetna preauthorizes your visit to a non-network provider prior to the visit, network benefits will be paid. Otherwise, non-network benefits will be paid, and the claim will have to be resubmitted for review and adjustment, if appropriate. Note: Even if approved by Aetna, non-network providers paid at the network level may bill you for any charges over the Aetna allowed amount for covered services. You are responsible for these charges.

In-Network Out-of-Pocket Maximum: This is the maximum out-of-pocket amount you are responsible to pay for in-network covered expenses per plan year. In-network deductibles, office visit copays, and coinsurance all apply to your maximum in-network out-of-pocket expense. After you reach the in-network out-of-pocket maximum, TRS-ActiveCare pays 100% of the allowable amount for covered in-network charges for the rest of the plan year.

Please Note - The Bariatric Surgery copay does not apply to the out-of-pocket maximum under the TRS-ActiveCare 2 plan.

Out-of-Network Out-of-Pocket Maximum: This is the maximum out-of-pocket amount you are responsible to pay for out-of-network covered expenses per plan year. Out-of-network deductibles and coinsurance apply to your maximum out-of-network out-of-pocket expense. After you reach the out-of-network out-of-pocket maximum, TRS-ActiveCare pays 100% of the allowable amount for covered out-of-network charges for the rest of the plan year.

All inpatient admissions should be preauthorized at least two working days before admission, or, in the case of an emergency, within 48 hours after admission.

Primary care means care provided by family practitioners, internist, OB/GYNs and pediatricians. All other physicians are specialists.

Aetna will review the medical necessity of your treatment prior to the final benefit determination. If the treatment or service is not medically necessary, benefits will be denied. There is a $250 penalty for failure to preauthorize a medically necessary admission to a non-network hospital. The penalty will be deducted from any benefit payment that may be due for the admission. The penalty is in addition to the deductible or out-of-pocket maximum.

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