1. Will there be any changes to my benefit plans? The Plan will continue to offer the existing 21 plan designs in addition to new plan options. The core benefits have remained the same, however minor changes have been made. Prior to transition you will be receiving information on how to access your new plan documents and plan summaries. Please review the documents carefully upon receipt.


2. Will I be able to switch my benefit plan at time of transition? Yes. If at time of transition, if you as an employer would like to offer your employees additional plans or revise your current benefit options, you and your employees will be required to complete the necessary paperwork to make the change. Additional information will be included in your renewal package and additional information will be sent to you prior to your transition date. As a member, you will only be allowed to change plans if your employer offers multiple plan options.


3. How are out-of-network claims paid? Elective Out-of-Network Services are paid at 110% of current year Medicare/RBRVS for Physicians and 140% of current year Medicare/RBRVS for facilities. Please refer to your plan document for detailed information regarding out-of-network services.


4. Will our prescription plan or coverage be affected? No. Your prescription benefits will remain the same as Express Scripts will continue to be the Pharmacy Vendor. However, you will receive a new prescription ID card at time of transition due to a change in your member number.


5. Will our dental benefits change? No. The Health Plan will continue to offer dental benefits through Delta Dental and Guardian.


6. Will Telemedicine services be offered through the Health Plan? Yes. The Health Plan will offer Telemedicine services through Teladoc.


7. Who will be administering COBRA and NJ Continuation of Care? OCA will continue to administer COBRA and NJ Continuation on behalf of the Health Plan. The program and process will not change for our members and our employees.


8. Will the Affiliated Physicians and Employers Health Plan still maintain its arrangement with OCA regarding HRA/FSA/DCA Administration? Yes. OCA will continue to be the HRA/FSA/DCA vendor for the Health Plan.


9. Is Quest still the exclusive lab for the Affiliated Physicians and Employers Health Plan? No. The Affiliated Physicians and Employers Health Plan will no longer have an Exclusive Lab arrangement. Members now can utilize any lab that participates within the Aetna network.


10. What happens to the deductible and MOOP that I have met while covered under the QualCare? A credit will be applied, for those members transitioning prior to January 1st , to both the deductible and MOOP in accordance with the plan policy. Deductible and MOOPs reset every calendar year.


11. What happens if I am currently in an Appeal stage with QualCare? All Appeals will be handled in their entirety by the QualCare team until all levels of appeal are completed.


12. I am expecting a baby, how will the transition effect my benefits? If you are expecting a baby, your care and benefits will continue for continuity of care with no disruption of services or providers. However, members will be required to complete a transition of care form.


13. If I currently have a prior authorization with QualCare, will I have to obtain a new authorization with Aetna? No. You will not have to authorize services again. If authorization was already completed with QualCare, the information will be passed onto the Aetna Care Management team for continuity of care.


14. What if I am currently under the care of a provider who does not take Aetna? The Aetna Care Management Team, in collaboration with your provider, will develop a transition plan, if applicable, to provide the best quality of care and continuity of treatment(s).


15. What happens if I am inpatient in the Hospital during the transition? There will be no impact to your coverage. Your inpatient admission will be handled according to your plan benefits.


Cosmo Insurance Agency is an independent insurance agency serving surrounding communities in New Jersey. Cosmo keeps its promise to assure an efficient and creative approach to the services we offer. Each of our clients experience a personalized and long-term relationship with us. Our New Jersey based team of health brokers guides our clients in helping them choose the most cost-effective options. By incorporating the latest in technology-based tools and laws on healthcare, employee benefits, life insurance and finance, we keep our clients up-to-date with the plans that encompass all of their needs, whether it is individual or group insurance.





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