Aetna Medicare Advantage for Plan Year 2019

Mike Zanyor from the STFA/NCO Associations is on the Plan Design Committee for the State Health Benefits and has been in regular contact with the FTA and me specifically as the Association Liaison regarding the changes in the Medicare Advantage plans.

Due to the volume of information he has provided me and associated attachments, I am asking you to post this information on the FTA website bulletin board in a manner that would make it user friendly to members accessing it.

Mike Zanyor took the time out to come to our open meeting on November 3rd to explain much of this information to the members in attendance and was very well received. He then attended a meeting/conference call this last week to get additional information for us retirees and ask the questions many of us had. The e-mail I am forwarding answers many of those questions.






Subject: Aetna Medicare Advantage for Plan Year 2019

Date: 11/15/18 09:40:41 PM

From: “Michael Zanyor” <>


I apologize in advance for the delay, but I was waiting on some clarification from Aetna and Pensions before sending this email out.  I will attempt to be as clear as possible, but if there are any questions please ask.

First, a few main points you should know:


  1.  Medicare Advantage (MA) Plans are also known as Medicare Part C plans and “Eggwhips” (EGWP: employer group waiver plans) – it is a generic term that describes the type of plan but not extend of coverage, different MA plans have different coverage.  This MA plan is specifically for NJ public employees.  THIS DOES NOT PERTAIN TO MEMBERS COVERED UNDER THE EDUCATORS’ PLAN (SEHBP) – THAT MA IS SLIGHTLY DIFFERENT.


  1.  The changeover will ONLY impact current medicare enrollees or members&spouses who become medicare eligible in 2019.  Medicare enrollment is mandatory at age 65.


  1.  ALL medicare covered employees will be moved from their current plan into the Aetna MA PPO Extended Service Area plan on January 1, 2019 unless they “opt-out”.


  1. Referrals ARE NOT needed under this plan.


  1.  There is no open enrollment period for any retiree (regardless of whenther medicare or non-medicare).  Instead, the following rule applies: any elective change is binding for one year from date of selection; an involutnary change can be changed at any time.  This is an important item to consider if opting out.


  1.  The only plans available if a member opts out of MA and instead chooses medicare and a SHBP plan are Horizon products and they are: NJ DIRECT1525, NJ DIRECT2030, Horizon HMOHorizon HMO1525Horizon HMO2030; Direct 15 is not an option.  Opt outs must be submitted before the end of December 2018.  REMEMBER THIS DECISION WILL BE BINDING FOR ONE YEAR.  However, if they are rolled over in January and don’t like the coverage, they can then ELECT to go to different plan and then be locked-in for one year from the date of the elective change.


  1.  In speaking to several retirees and other unions, going with MA or staying status quo is very much a personal decision that is truly case by case.


  1.  The selling point of the MA plan is only one card is needed and Aetna handles all the paperwork.


  1.  This doesn’t affect prescription coverage. OptumRx is still handling that aspect.


How Aetna MA works and covered services:


  1.  There is no in-netowrk/out-of-network issue.  If a provider accepts payment from Medicare, the plan will cover services from the provider.  HOWEVER, if the provider does not accept Medicare – even if in the Aetna network – services are not covered.  This was true even before MA was offered – you couldn’t use Direct15 if you have medicare and the provider doesn’t accept Medicare.


  1.  The MA plan covers some things differently from the Direct15 and Aetna Freedom Plans.  For example, the MA copay is $15 for all doctors (regular and speciality), max out of pocket (OOP) is $1000 per person, ER visit is $75, and medical transportation and hospital are fully covered.  The non MA plans have higher max OOP’s, $15 copay regular, $25 specialist, co-insurance (cost sharing) for hospitalization, medical transporation, and other items.  I’ve attached PDF’s with cost breakdowns.


  1.  Some hospitals and providers will say they don’t take Aetna MA even thought they take Medicare.  Per Aetna, if this happens, a member should call customer service and they will clarify it with the provider.  Sloan Kettering and Hospital For Specialized Surgery in NYC were identified by Aetna as examples that have told patients they don’t take the plan but they do since they take Medicare.  Aetna also advised if a member is billed, the member should forward it to Aetna.


  1.  Chriopractic visits covered under Medicare do not require a Prior Authorization (PA)-it is waived; non-medicare covered chriopractic visits are limited to 30 per year.  You may have heard or seen commercials and mailings say to not enroll in Aetna MA -some of these are sponsored by the Association of NJ Chiropractors.  I have a copy of a letter they have sent out – it is misleading propoganda.


  1.  Preventitive OGBYN visitis covered at 100% go from once every 12 months to once every 24 months.  Any other visits subject to $15 copay.




I personally see no benefit of opting out – the opt-out coverage is similar and the members’ OOP is higher.




Since it is a forced change, I would recommend trying the new coverage starting in January and then switching if unsatisified.  If a member opts-out, he or she can’t return until a year from now.  However, I’m sure there are individual circumtances in which opting-out is prudent.


Finally, I have attached a comparison charts, a coverage summary sheet, a list of copays for the Aetna MA, a brochure from Aetna, and and change form for your reference.  I have also included a link to the NJ DOPB website and the Aetna NJ MA website.

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