Medical plan
Do I have to participate in Katy ISD medical coverage?

No. But you should take time to learn about the medical coverage available to you through the Katy ISD medical plan options as well as any other source available to you, such as your spouse’s medical benefits plan. Compare and consider the cost of coverage for each option. This can help you decide which coverage works best for you and your family.

The Affordable Care Act, which has been in effect since March of 2010, requires most Americans to have health care coverage that meets minimum guidelines for affordability and value. Katy ISD plans meet those guidelines for value and affordability. Therefore, if you are eligible for Katy ISD health plans, it is likely you won't be eligible for any of the subsidies otherwise available in the Federal Heath Insurance Marketplace.

Do I get a member ID card after I enroll for coverage?

You receive two ID cards. Your Aetna ID card contains medical information. This card lists a unique ID number (not your SSN) for medical claims purposes. You also receive an Express Scripts ID card to use when purchasing prescription drugs. This card has a unique ID number as well.

To request additional or replacement cards, call Aetna at 877-224-6857 (8 a.m. to 6 p.m. Central Time, weekdays (except holidays) or Express Scripts at 855-712-0331.

What’s the difference between a copay and coinsurance?

— A copay is a set fee that you pay for certain services, such as prescription drugs. Copays also apply to doctor office visits and services performed during office visits under the Open Access option.

— This is the percentage of expenses for covered services that you pay after you meet your deductible and until you reach your annual out-of-pocket maximum. 

What is a limited fee schedule?

Non-emergency services and procedures are paid according to an established fee schedule (a set rate for a particular service). You are responsible for paying the difference between the covered amount and the amount the facility charges. Call Aetna before going out-of-network to help you understand the costs associated with your decision.

Just because your doctor is in-network, the facility in which you are treated or are referred to might not be in the network. Log on to Aetna Navigator and check DocFind to check the status of the treatment facility you want to use and call the provider to confirm.

What’s a primary care physician (PCP)?

A primary care physician (PCP) is a provider who provides most of your primary and preventive care, and who is available to refer you to specialists if necessary. While there’s no requirement to designate a PCP and you can change providers at any time, most people have a PCP overseeing their care. While obtaining a referral to see a specialist isn’t necessary, primary care physicians can be a valuable resource in identifying the type of specialist you need to see and providing a list of specialty providers who might work well for you.

What does pre-certification mean?

Pre-certification is the process of obtaining Aetna’s approval before certain health care services or procedures are performed. Pre-certification is required for all in-patient admissions and a number of outpatient services, including high tech radiology procedures, such as MRIs and CT scans. For a full list of services or supplies that require pre-certification or pre-notification, log on to Aetna Navigator or call Aetna at 800-333-4432, weekdays between 8 a.m. and 6 p.m. Central Time. Failure to get pre-certification when required results in a penalty of 50% before the appropriate coinsurance is applied or, in the case of high tech radiology, the procedure is not covered.

Although your provider may contact Aetna for authorization on your behalf, you’re ultimately responsible for making sure Aetna’s approval is obtained or the care or service you receive may not be covered.

If you’re unable to obtain pre-certification due to an emergency, report the emergency to Aetna as soon as possible to comply with this requirement.

What does "usual, customary and reasonable" mean?

Usual, customary and reasonable (UCR) limits are based on prevailing costs of services or supplies for the geographic area in which the services or supplies are provided. In-network services are contracted and cannot exceed UCR limits. If you use an out-of-network facility for emergency care, the plan pays its percentage of coverage up to the UCR amount, not the facility’s actual charges. You’re responsible for paying the difference between the covered amount and the amount the facility charges.

Can I go to an emergency room for care?

It's important not to use hospital or standalone ERs for minor illnesses or injuries, even after hours, especially when you have the option of urgent care centers and walk-in retail clinics. Unnecessary trips to the ER cost everyone money. 

The ER copay is $250 for the Memorial Hermann ACO plan and $750 for the Choice POS II plan. So it pays to plan ahead. Find out now where clinics and other facilities are so you know where to go in case an illness or injury happens at an inconvenient time. If you need help making a decision, call the Aetna 24/7 Nurse Line.

If I meet the annual out-of-pocket maximum, do I have to pay more if I need additional services?

Generally, no. Once you meet the out-of-pocket maximum amount, the plan pays 100% of all covered expenses you have for the rest of the year. This doesn’t include non-covered expenses such as amounts over the set reimbursement limits for emergency care.

What’s the preventive care benefit?

You and your covered family members receive 100% coverage with no annual deductible for preventive care expenses.

What’s considered “preventive care”?

Preventive care services help maintain health and prevent disease and include annual physicals, well-woman exams, prostate check ups, immunizations and more. If you’re not sure what’s considered preventive care, call Aetna customer service at 877-224-6857, available 8 a.m. to 6 p.m. Central Time, weekdays (except holidays).

Can I have Katy ISD medical coverage and Medicare?

Yes. If you have Katy ISD medical coverage as an active employee, that coverage is primary and Medicare is secondary. For more information, please contact Medicare.

What can I do if my medical claim is denied?

Call Aetna at 877-224-6857 8 a.m. to 6 p.m. Central Time, weekdays (except holidays)

Where can I get medical plan provider directories?

All medical plan options offer network care through Aetna. You may request printed directories by calling Aetna; however, the most up-to-date information about providers can be found by logging on to Aetna Navigator and checking DocFind or by contacting Aetna member services at 877-224-6857 8 a.m. to 6 p.m. Central Time, weekdays (except holidays).

Remember that directory information is for reference only. Always verify the provider's address, phone number, specialty and any other information before making an appointment.

Is pregnancy a pre-existing condition under the Aetna options?

No. Pregnancy isn’t considered a pre-existing limitation for purposes of the plan.