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.

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 blood work?

Quest Diagnostics 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 privileges 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 the SuperMed PPO Network, and in all other states they can access the Cigna PPO Network. 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.
Additional healthcare information

Age 65 and Above

Medicare

When I retire from NA, what are my health care options until I reach age 65?

If eligible, you may enroll in NA’s post-retirement health care plan per the collective bargaining agreement in effect at the time of your retirement. If you do not qualify for retiree benefits, a COBRA plan may be available to you through the District. You can also choose to purchase a plan through the market place on healthcare.gov.

Does NAR provide help with medicare supplementary insurance decisions?

Dave McDonald is a board member of a non-profit, Pennsylvania Healthcare Benefits Solutions Program (PHBSP). Our group 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 board member of Pennsylvania Healthcare Benefits Solutions Program (PHBSP) 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 twice yearly (usually fall & spring), 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 up to a $100 stipend per month from the state which is added to your pension payment.

What health care plan is offered by North Allegheny?

Currently, Aetna PPO is the plan sponsored by the District. For more information about the plan or to enroll, contact Katie Goehring in NA Human Resources. 412-369-5546.

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?

HOP is short for Health Options Program from PSERs,  eligible for Premium Assistance. It offers two Medicare supplemental plans and several Medicare Advantage plans. Careful research is recommended. Attending on of NAR’s Medicare workshops is advised.

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.

All Advantage plans have some kind of network of hospitals and physicians, so research is advised.

How do I get a supplement plan?

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

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

If you carry the District’s dental plan to the point of Medicare eligibility, you will be eligible to continue the insurance post age 65 by paying the full monthly cost of the premium. Vision coverage is not available through the District post age 65.

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 or when HOPs decides to offer a true Open Enrollment Period.

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?

Check Medicare booklet but some examples include:

  • 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 usually providing a 5 tier formulary.

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 UPMC plan for pre-65 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.

What is an Annual Notice of Change?

Every year your insurance carrier is required by law to notify you of any changes in premiums, networks, deductibles, co-payments, prescription drug formulary, etc. DO NOT IGNORE studying this. If changes are made and you are unaware of them, you must accept the changes for the entire coverage year. If you study the changes and don’t want them, you are free to choose another insurance carrier for the next year.