Frequently Asked Health Care Questions


Note: The information contained here is:

  • Not meant to be self-explanatory
  • Not meant to be all inclusive
  • Not meant to provide advice

You are encouraged to do your own research (Medicare itself, Social Security Administration, APPRISE, PA Department of Aging, etc.) to find the answers to your particular questions or to your particular situation.

Under Age 65

UPMC

How will I know if my doctor is Level 1, Level 2, or Out-Of-Network?

You may follow the instructions that were distributed when the change in carrier was announced. Using the UPMC HealthPlan website, you can find MyCare Advantage PPO Level 1 and Premium Network Plans – PPO and EPO Plans (Level 2) doctors. If your doctor does not come up on your search, he/she is out-of-network.

Which network does our UPMC plan fall under?

The network which receives the highest level of coverage under our plan design is the MyCare Advantage PPO Level 1. You may see a lot of other UPMC products and networks listed on the website, but it is the MyCare Advantage PPO Level 1 that you will use to search.

What additional costs are associated with Level 2 or Out-Of-Network services?

Level 2 and Out-Of-Network services require more cost-sharing for the member. In each of these tiers, there is a deductible and coinsurance as well as increased copays. Please refer to your medical schedule of benefits for specific costs.

What are the copays under the new plan?

If you utilize Level 1 doctors, there is no change in your copay amounts. You will experience higher copays if you use doctors who do not participate in the MyCare Advantage PPO Level 1. Please refer to your medical schedule of benefits for specific costs.

Which hospitals fall in the Level 1 network?

All UPMC Hospitals. Please refer to your UPMC Welcome Guide for a full listing of other participating hospitals.

What labs may be used for bloodwork?

QuestDiagnostics is the most common lab used under the UPMC plan. LabCorp will no longer be in-network. Staff may search for the nearest lab facility on the UPMC HealthPlan website.

If I see a Level 2 doctor and he/she orders blood work, will I receive Level 1 benefits for that bloodwork if the labs are done at a Level 1 facility?

Even if the ordering physician is a Level 2 doctor, you will receive the highest benefit (Level 1) if using in-network lab facilities such as Quest Diagnostics.
If my doctor is Level 1 or Level 2 but only has admitting priveleges to an out-of-network hospital, how will that affect me?
A provider needs to have privileges – or an admitting arrangement – at a participating hospital in order to be a participating provider. An admitting arrangement is an agreement with a participating provider in the same specialty to admit for the provider who does not have privileges at a participating hospital.

Can I still go to MedExpress?

MedExpress facilities vary in tier by location. Some may fall into Level 2 with increased copays and some may fall out of network completely. As an alternative, UPMC Urgent care facilities are Level 1 providers.

Will Optum Rx still be the pharmacy used for mail-in medications?

Optum Rx will no longer be used effective January 1, 2017. UPMC utilizes ExpressScripts as their pharmacy provider. Most pharmacies in the area will be approved as in-network with the exception of Walgreens.

Can I appeal to have a medication covered?

Yes a member has the right to file an appeal If their medication is not on UPMC’s formulary.

Will I be forced to use mail order for my maintenance medications?

Unlike Optum Rx, UPMC does not have mandatory mail service for maintenance medications. You have the opportunity to use ExpressScripts if you choose to obtain 90-day supplies at a minimal one-copay.

How do I receive care if traveling outside of Western PA?

If you have a true emergency, you should go to the nearest emergency room for care. You will receive the highest level of benefit for emergency care. If your need for care is less urgent, you can either search for an out-of-area provider on UPMC HealthPlan’s website or contact Assist America for help coordinating your care. You may only use the out-of-area network for urgent or emergent care if you reside in western PA.

How does my college student living out of state receive in-network services under this plan?

Your children are covered up to age 26 no matter where they live. If your covered dependents live outside western Pennsylvania, they have access to great care -whether they’re in college or working. They would have access to our national vendors. In Ohio they can access Medical Mutual of Ohio and in Eastern PA and all other states they can access Multiplan/PHCS. Please contact Member Services to assist in finding a provider/facility in those national networks.

What do I do if I live outside of Western PA?

If your home zip code falls outside of the western PA area, you will have the opportunity to enroll in an out-of-area plan. This plan has only 2 levels of benefits (as opposed to 3) and is only available based on zip code analysis. If you believe you qualify for this plan, please contact your Katie Goehring at CAO.

Age 65 and Above

Medicare

When I retire from NA, what are my health care options?

You may enroll in NA’s post-retirement health care plan and pay whatever premium the District pays for you, according to the NASD/NAFT contract in effect at the time of your retirement. or you may purchase a plan through a market place of plans.

Does NAR provide help with medicare supplementary insurance decisions?

Dave McDonald is a trained volunteer for APPRISE, an agency affiliated with the PA Dept of Aging and has information comparing a number of popular health care plans in both services and costs.

You can contact Dave McDonald at nar@naretired.org.

Where can I find a comparison of Medicare supplementary insurance plans?

Dave McDonald is a trained volunteer for APPRISE, an agency affiliated with the PA Dept of Aging and has information comparing a number of popular health care plans in both services and costs.

Also to be considered in the Medicare decision is a choice between a Medicare supplement plan or a Medicare Advantage plan. Furthermore, choosing between a Health Options Plan (from PSERs) or the District’s own retiree plan should be studied.

NAR, at least once a year, sponsors a comprehensive program addressing these issues. However, should a retiree be turning 65 prior to our program, contact Dave McDonald.

You can contact Dave McDonald at nar@naretired.org for further details.

What is Premium Assistance?

 

As long as you remain in a health plan offered by PSERs or one offered by North Allegheny, you are eligible to receive a $100 stipend per month from the state.

What health care plan is offered by North Allegheny?

Currently, Advantra (Aetna) manages the plan, and Katie Goehring from Human Resources is the District contact. 412-366-2100

What is APPRISE?

Overseen by the PA Department of Aging, APPRISE assists seniors with health care plans options and decisions. This organization objectively, with no bias, compares Medicare plans available to seniors in Western Pennsylvania.

Statewide hot-line: 800-783-7067
Allegheny County: 412-661-1438
Note: Each PA County has its own APPRISE program.

When I turn 65, what are my health care options?
  • You may accept one of the plans offered by Health Options Program
  • You may elect North Allegheny’s post 65 coverage plan
  • You may go to the health care market place.
What is HOP?

A set of health plans offered by PSERs, eligible for Premium Assistance.

What is the difference between a Medicare supplement plan and a Medicare Advantage plan?

With a supplement (often called Medigap), Medicare and its coverage is your primary insurance, typically covering 80% of costs. The remaining 20% is covered by whatever supplement plan you purchase. Supplement plans typically do not include a prescription drug plan which you would have to purchase separately.

With a Medicare Advantage Plan (managed care), whatever plan you choose is your primary coverage and you are covered to the conditions of the policy. This plan typically includes prescription drug coverage.

How do I get a supplement plan?

You can purchase through HOPs or through any Medicare approved company which offers supplements.

After 65, will I be able to purchase NA's dental plan and vision plan?

Yes, by paying monthly premiums.

When I near 65, what information will I receive?
  • You will receive copies of many Medicare options.
  • You may request copy of NA’s post 65 health care plan.
  • You will receive notice from PSERs of the Health Options plans it offers.
If I am 65 and elect NA's post 65 plan, can I later change to a HOPs plan?

No, typically 6 months after you receive your offers from HOP, the offer lapses, except for life changing (qualifying) events.

If I am 65 and elect a HOP plan, can I later change to NA's plan?

There is no assurance this can occur. Life changing events may affect this.

What are life changing or qualifying events?
  • You lose your employer coverage
  • A dependent status change (marriage, divorce, death of spouse, addition of a dependent)
  • A plan approved for PA terminates
  • A person moves of out the plan’s coverage area
What is the difference between an HMO and a PPO?

An HMO (Health Maintenance Organization) requires the use of a network of providers and referrals. Out of network services are not covered.

A PPO (Preferred Provider Organization) provides both in and out of network services and typically does not require referrals.

What is the Open Enrollment period?

A limited period of time in the fall when people may change their Medicare plans.

What is the donut hole?

A service level when you are responsible for the total costs of any prescription drugs you may need.

What is Medicare A, B, C, and D?

A – Covers hospital expenses (currently there is no premium for this)

B – Covers medical, surgical and physician expenses (your premium based on your income is deducted from your Social Security benefit. If you are not on SS, you will be billed monthly.)

C – Medicare Advantage, premiums of which you pay to the company you choose

D – Prescription Drug plan providing 3 tiers of coverage

I spend 5 or 6 months outside of PA each year. What must I do to be sure my insurance will follow me?

If you are covered by the District’s current UnitedHealthcare plan for retirees, consult that plan’s provisions. If you are covered by another plan and are post 65, consult the provisions of those individual plans.

Each plan has some sort of concierge service with an 800 number whose representative can advise you more specifically.

Please contact Dave McDonald at nar@naretired.org for further details.