Consumer Benefits of Tiered Networks Developed in response to employer demand Tiering allows member choice while demonstrating cost variances amongst providers Tiering based on quality & cost Focus on consumer friendly materials to assure member understanding of benefits Current Tiering options available: Specialists Hospitals Integrated Systems (PHOs, PCMH, ACOs)
2
Aexcel® Specialist Network
12 specialty categories represent 70% of specialty spend and 50% of overall medical spend
Designed for all Size Employers and Individuals
Cardiology Gastroenterology General Surgery Orthopedics Neurology Neurosurgery
Concentric Network Plan Design Aexcel Network Designated physicians, par PCPs, par hospitals, all par physicians in other specialties & ancillaries
Obstetrics/Gynecology Cardiothoracic Surgery Vascular Surgery Otolaryngology (ENT) Plastic Surgery Urology
Out-of-Network Nondesignated physicians AND Non-par physicians & other health care professionals
Multi-tier Network Plan Design Additional Physician Quality Metrics Applied to Aexcel Designated Physicians Use of Technology (BTE Physician Office Link, CCHIT-endorsed EMR/ePrescribing) Alignment with Institutes of Quality® (IOQ)
Tier 1 Designated physicians, par PCPs, par hospitals, all par physicians in other specialties & ancillaries
Tier 2
Out-of-Network
Nondesignated physicians
Non-par physicians & other health care professionals
Aetna Choose and SaveSM Designed for Large, Multi-Site Self-funded Employers
Highlights Hospital tiering is based on quality of care metrics and cost effectiveness Leverages the Aexcel Specialist Network Hospital Quality Metrics
In-Network Tier 2
Out-of-Network Non-Aetna network
Outpatient Facilities
Aetna’s nationwide network
90% coinsurance
65% coinsurance
50% coinsurance
In-Network Tier 1 Selected doctors and hospitals
Adverse Events 30 Day Hospital Readmission Average Length of Stay CMS Process of Care Weighted Index
In-Network Tier 1 All Aexcel designated specialists and designated hospitals, plus: • All par PCPs • All par physicians in other specialties • All par ancillaries • All outpatient facilities
In-Network Tier 2
Out-of-Network
Par, non-designated physicians and hospitals
Non-par physicians and other health care professionals
4
Aetna Savings Plus Designed for Individuals & Small Employers
Concentric Network Plan Design
Network Selected doctors and hospitals Outpatient Facilities
In-Network Tier 1 All designated physicians and designated hospitals, plus: • All par physicians in non-tiered specialties • All par ancillaries • All outpatient facilities
Out-of-Network Non-selected physicians and hospitals plus non-par health care professionals
Out-of-Network Par, non-designated physicians and hospitals plus non-par physicians, hospitals and other health care professionals
Hospital Quality Metrics • Adverse Events • 30 Day Hospital Readmission • Average Length of Stay • CMS Process of Care Weighted Index
Multi-tier Network Plan Design
In-Network Tier 1 Selected doctors and hospitals Outpatient Facilities
In-Network Tier 1 All designated physicians and designated hospitals, plus: • All par physicians in non-tiered specialties • All par ancillaries • All outpatient facilities
In-Network Tier 2 Non-selected physicians and hospitals
In-Network Tier 2 Par, nondesignated physicians and hospitals
Out-ofNetwork Non-par physicians & other health care professionals
Out-of-Network Non-par physicians, hospitals and other health care professionals 5
Specialized Network Solutions
Providing members access to designated facilities that meet quality and cost criteria for specific conditions Institutes of ExcellenceTM (IOE)
Large, National – extensive participation requirements
Large, Regional
Small, National – 4-5 facilities designated for cardiac and orthopedic
Evidence-based Quality Metrics
Tools and Informational Resources
* Currently in development. Changes may occur prior to program launch. Exceptions and limitations may apply and program may not be available in all areas.
6
Improving the Healthcare System for Consumers and Employers
