Citi Benefits Handbook
How the Plan Works
This section contains more detailed information about HDHP's provisions and how this medical plan works.
You have a choice of using in-network providers or out-of-network providers. Using in-network providers saves you money in two ways. First, in-network providers charge special, negotiated rates, which are generally lower than the MAA. Second, the level of reimbursement for many services is higher when you use an in-network provider.
A directory of network providers is available directly from the Claims Administrator.
- Aetna: www.aetna.com; select the Aetna Open Access, Choice POSII Open Access Plan or call 1 (800) 545-5862
- Anthem BlueCross BlueShield: www.anthem.com; select the PPO or call 1 (855) 593-8123
Deductible and Coinsurance
You must meet an annual deductible of $1,800 for individual (employee only) coverage or $3,600 for family (two or more in a family) before the plan pays any benefits, unless the service is covered at 100%, such as preventive care.
The deductible applies to all covered expenses except preventive care and must be met each calendar year before any benefits will be paid. Whether you visit an in-network provider or an out-of-network provider, your costs count toward both deductibles.
Other than for services not subject to the deductible, any one or a combination of family members must meet the full family deductible before the plan pays any benefits. There is no individual limit within the family deductible limit. The deductible can be met as follows:
- Employee only: The individual deductible of $1,800 applies.
- Two or more in a family: The $3,600 family deductible applies, one or a combination of all family members must meet the full family deductible before the plan pays any benefits.
- Note: Once you have met the deductible, the plan normally pays 80% of the negotiated rate for covered health services if you or your covered dependent uses an in-network hospital/provider.
- Employee only: The individual deductible of $2,800 applies.
- Two or more in a family: The $5,600 family deductible applies, one or a combination of all family members must meet the full family deductible before the plan pays any benefits.
- Note: Expenses are normally reimbursed at 60% of MAA for claims for covered services submitted for an out-of-network provider. Providers may balance bill you for the charges above MAA, and you are responsible for those charges.
Deductible expenses cross-apply between in-network and out-of-network limits.
Your out-of-pocket maximum is $5,000 individual/$10,000 family (out-of-network $7,500/individual and $15,000/family).Each of your covered family members has an individual out-of-pocket maximum of only $6,850 for in-network coverage. After reaching that amount, your plan will cover 100% of that individual's in-network health care expenses for the rest of the year. The amount includes the $1,800/individual and $3,600/family (out-of-network $2,800/$5,600) deductible, coinsurance and any medical copayments. This represents the most you will have to pay out of your own pocket in a calendar year.
Only your deductible, coinsurance amount, and any applicable medical copayments — not the amount billed over MAA by your doctor or facility — is applied to your out-of-pocket maximum. The maximum can be met as follows:
- Employee only: $5,000 (out-of-network $7,500)
- Two or more in a family: The $10,000 (out-of-network $15,000) family out-of-pocket maximum applies. Each of your covered family members has an individual out-of-pocket maximum of only $6,850 for in-network coverage. After reaching that amount, your plan will cover 100% of that individual's in-network health care expenses for the rest of the year. Once the $10,000 family in-network out-of-pocket maximum is met, your plan will cover 100% of the family's in-network health care expenses for the rest of the year. Eligible expenses can be combined to meet the family out-of-pocket maximum, which means that one or a combination of all family members must meet the full family out-of-pocket maximum
Once this out-of-pocket maximum is met, covered expenses are payable at 100% of the negotiated rate (or of MAA) for the remainder of the calendar year. However, the plan does not cover the amount over MAA. You can still be billed for that amount and are responsible for paying that portion.
Not all expenses count toward your out-of-pocket maximum. Among those that do not count are:
- Expenses that exceed MAA;
- Charges for services not covered under the plan, and
- Any expense that would have been reimbursed if you had followed the notification requirements for care.
Out-of-pocket expenses cross-apply between in-network and out-of-network limits.
Covered expenses are not subject to the deductible and are covered at 100% when using in-network providers or 100% of MAA when using out-of-network providers.
Preventive care services include:
- Routine physical exams: Well-child care and adult care, performed by the patient's provider at a frequency based on American Medical Association guidelines or as directed by the provider. For frequency guidelines, call the Claims Administrator;
- Routine diagnostic tests: For example, CBC (complete blood count), cholesterol blood test, urinalysis; and
- Routine well-woman exams.
In addition, the plan will cover cancer-screening tests, well-adult immunizations and well-child care and immunizations at 100%. Cancer screenings are:
- Pap smear performed annually;
- Colonoscopy; and
- Prostatic-specific antigen (PSA) screening annually with a digital rectal exam in men age50 and older.
Preventive care services covered in the network at 100% will be reviewed annually and updated prospectively to comply with recommendations of the:
- United States Preventive Care Task Force;
- Advisory Committee on Immunization Practices that have been adopted by the director of the Centers for Disease Control and Prevention; and
- Comprehensive Guidelines Supported by the Health Resources and Services Administration.
For more information on what is considered preventive care, see "Preventive Care."
Routine health screenings are covered at:
- 100%, not subject to deductible; and
- 100% of the MAA, not subject to deductible (for care received from an out-of-network provider).
The annual deductible does not apply to routine care. However, routine care is subject to the following limits:
- Routine vision exam: Limited to one exam per calendar year; and
- Aetna: covered expenses include a complete routine eye exam that includes refraction and glaucoma testing. A routine eye exam does not include a contact lens exam.
- Routine hearing exam: Limited to one exam per calendar year.
Aetna: covered expenses include charges for an audiometric hearing exam if the exam is performed by:
- A physician certified as an otolaryngologist or otologist; or
- An audiologist who:
- Is legally qualified in audiology; or
- Holds a certificate of Clinical Competence in Audiology from the American Speech and Hearing Association (in the absence of any applicable licensing requirements); and
- Performs the exam at the written direction of a legally qualified otolaryngologist or otologist.
To be sure your claim for a routine exam is paid properly, ask your physician to indicate "routine exam" on the bill. If a medical condition is diagnosed during a routine exam, your claim for a routine exam still will be paid as explained above, provided the bill is marked "routine exam."
After you meet your annual deductible, hospital care (inpatient and outpatient) will be reimbursed at:
- 80% for care received from an in-network provider; or
- 60% for care received from an out-of-network provider.
Precertification of an inpatient admission is required. Precertification is also recommended for certain outpatient procedures and services.
Aetna: Precertification requirements apply to both inpatient care and partial hospitalizations.
After you meet your annual deductible, emergency care will be reimbursed at 80% for care received from both in-network and out-of-network providers.
Non-emergency services provided in an emergency room are not covered.
Aetna: When emergency care is necessary, please follow the guidelines below:
- Seek the nearest emergency room, or dial 911 or your local emergency response service for medical and ambulatory assistance. If possible, call your physician provided a delay would not be detrimental to your health.
- After assessing and stabilizing your condition, the emergency room should contact your physician to obtain your medical history to assist the emergency physician in your treatment.
- If you are admitted to an inpatient facility, notify your physician as soon as reasonably possible.
- If you seek care in an emergency room for a non-emergency condition, the plan will not cover the expenses you incur.
Urgent care centers will be reimbursed at:
- 80% of the negotiated rate (after the deductible is met) for care received from an in-network provider; or
- 80% of MAA (after the deductible is met) for care received from an out-of-network provider
Aetna: Call your PCP if you think you need urgent care. You may contact any physician or urgent care provider, in- or out-of-network, for an urgent care condition if you cannot reach your physician. If it is not feasible to contact your physician, please do so as soon as possible after urgent care is provided. In-network providers are required to provide urgent care coverage 24 hours a day, including weekends and holidays. If you need help finding an urgent care provider you may call Member Services at the toll-free number on your I.D. card, or you may access Aetna's online provider directory at www.aetna.com. Follow-up care is not considered an emergency or urgent condition and is not covered as part of any emergency or urgent care visit. Once you have been treated and discharged, you should contact your physician for any necessary follow-up care.
Anthem BCBS: When available, Anthem uses MAA when determining plan payment for an out of network provider. In the absence of MAA data, Anthem may calculate payment based on billed charges.
Aetna Aexcel Specialists
Aexcel is a designation within Aetna's network that includes specialists who have demonstrated effectiveness in the delivery of care based on defined measures of clinical performance and cost-efficiency. Currently, there are Aexcel-designated physicians in 12 medical specialty categories: Cardiology, cardiothoracic surgery, gastroenterology, general surgery, obstetrics and gynecology, orthopedics, otolaryngology, neurology, neurosurgery, plastic surgery, urology, and vascular surgery.
Aexcel-designated specialists are currently available to members in AZ, CA, CO, CT, DC, DE, FL, GA, IL, IN, KS, KY, MD, MA, ME, MI, MO, NJ, NV, NY, OH, OK, PA, TX, VA, and WA.
When you visit an Aexcel specialist you do not need a referral. The plan will pay 90% of covered expenses after your deductible for Aexcel specialists. To find an Aexcel specialist visit, www.aetna.com/docfind; select the Aetna Standard Plans, Aetna Select, and look for the providers listed with the blue star. This blue star identifies the Aexcel specialists.
Mental Health/Substance Abuse
The Aetna/Anthem BlueCross BlueShield HDHP provides confidential mental health and substance abuse coverage through a network of participating counselors and specialized practitioners.
When you call the Claims Administrator at the telephone number on your ID card, you will be put in touch with an intake coordinator who will gather information from you and help find the right provider for you. In an emergency, the intake coordinator will also provide immediate assistance, and, if necessary, arrange for treatment in an appropriate facility.
You must call before seeking treatment for mental health or substance abuse treatment.
Mental health and substance abuse treatment benefits are subject to the same medical necessity requirements, coverage limitations, and deductibles that are required under the HDHP.
Mental health benefits include, but are not limited to:
- Assessment, diagnosis, and treatment:
- Medication management;
- Individual, family, and group psychotherapy;
- Acute inpatient care;
- Partial hospitalization programs;
- Facility-based intensive outpatient program services; and
- Psychological testing that is not primarily educational in nature.
No benefit will be paid for services that are not considered to be medically necessary.
Aetna: In addition to meeting all other conditions for coverage, the treatment must meet the following criteria:
- There is a written treatment plan supervised by a physician or licensed provider; and
- The treatment plan is for a condition that can favorably be changed.
Benefits are payable for charges incurred in a hospital, psychiatric hospital, residential treatment facility or behavioral health provider's office.
You must call the Claims Administrator to give notification of inpatient services. Inpatient services are covered only if they are determined to be medically necessary and there is no less intensive or more appropriate level of care in lieu of an inpatient hospital stay. After you meet your deductible, inpatient stays are covered at 80% of the negotiated rate when you use an in-network provider or 60% of MAA if you use an out-of-network provider. If it is determined that a less intensive or more appropriate level of treatment could have been given, no benefits will be payable.
Generally, inpatient services must be rendered in the state in which the patient resides, unless approved by the Claims Administrator in advance of the admission.
Aetna: Benefits are payable for charges incurred in a hospital, psychiatric hospital, or residential treatment facility. Covered expenses include charges for room and board at the semi-private room rate, and other services and supplies. Inpatient benefits are payable only if your condition requires services that are only available in an inpatient setting. Covered expenses also include charges made for partial confinement treatment provided in a facility or program for the intermediate short-term or medically-directed intensive treatment of a mental disorder. Such benefits are payable if your condition requires services that are only available in a partial confinement treatment setting.
You are encouraged to call the Claims Administrator for outpatient referrals. If you call and use the recommended provider, you will be reimbursed at 80% of covered expenses after the deductible is met. If you do not use an in-network provider, you will be reimbursed at 60% of MAA for covered services after the deductible is met.
Aetna: covered expenses include charges for treatment received while not confined as a full-time inpatient in a hospital, psychiatric hospital or residential treatment facility. The plan covers partial hospitalization services (more than 4 hours, but less than 24 hours per day) provided in a facility or program for the intermediate short-term or medically-directed intensive treatment. The partial hospitalization will only be covered if you would need inpatient care if you were not admitted to this type of facility.
Emergency care for mental health or substance abuse treatment does not require a referral. However you are encouraged to call the Claims Administrator within 48 hours after an emergency admission. The behavioral health provider is available 24/7 to accept calls.
The Claims Administrator will help you and your physician determine the best course of treatment based on your diagnosis and acceptable medical practice. The Claims Administrator will determine whether certain covered services and supplies are medically necessary solely for purposes of determining what the medical plans will reimburse. No benefits are payable unless the Claims Administrator determines that the covered services and supplies are medically necessary. See the Glossary section for the definition of medical necessity.
For more information about what your plan covers, see "Covered Services and Supplies." You may also contact your plan directly to confirm coverage of a particular service or supply and to find out what limits may apply.