December 15, 2007


 AVMA GHLIT switches PPO network

Change supports evolving needs of participants, helps manage costs

Posted Dec. 1, 2007

In a move designed to manage costs while continuing to provide valuable benefits to support the evolving needs of participants, the AVMA Group Health and Life Insurance Trust switched its preferred provider organization network to Aetna Signature Administrators, effective Dec. 1, 2007.

ActiveHealth Management, also an Aetna company, has assumed responsibility for the utilization review certification required for inpatient stays.

"After evaluating the existing PPO network and managed care services, the Trust determined that switching to these Aetna companies will provide participants with access to the high-quality care and valuable benefits they have come to expect from GHLIT," said Dr. Gary R. Holfinger, chair of AVMA GHLIT.

"The improved cost management resulting from this partnership between the Trust's medical insurance carrier, New York Life, and ASA is also expected to generate savings to GHLIT and its members that positively impact future premium rate actions, without sacrificing the level of quality or benefits," he said.

Aetna is a leading health care benefits company serving participants with information and resources to help them make better informed decisions about their health care. As part of Aetna, ASA is well-suited to help meet the Trust's needs, with more than 783,000 heath care professionals and nearly 4,700 hospitals nationwide participating in the network.   

Expansive network means limited disruptions

The transition to the ASA PPO network will, for the most part, be transparent to participants. The most visible change will be the issuance of medical identification cards bearing the ASA logo, which must be shown to participating providers to ensure receipt of the negotiated discounts. Beyond that, GHLIT plan benefits remain unchanged. 

Most important, because the ASA PPO network has an extensive list of participating providers, disruption of care is expected to be minimal.

"During the evaluation and comparison of the previous PPO network and the ASA network, the Trust and its advisers determined that the majority of participants will continue to have access to their existing providers on an in-network basis," Dr. Holfinger noted.

To establish whether or not a provider is part of the ASA PPO network, participants are encouraged to utilize DocFind, an online tool accessible via the GHLIT Web site at DocFind provides detailed information on participating physicians and other health care professionals, as well as pharmacies, hospitals, and other facilities and vendors.

By using DocFind, participants can search for providers based on geography, category, and type, as well as by name, gender, hospital affiliation, and languages spoken. The tool also provides detailed information on each provider, such as board certifications, hospital affiliations, education, patient age range, and whether new patients are being accepted. Professional medical survey results may also be accessed when available. Because DocFind is updated three times a week, the information available through the tool is current—often more current than printed provider directories. There can be changes in a PPO network, however, so prior to receiving care, it is important to verify that providers are still participating and that they have privileges with an in-network hospital.  

In-network versus out-of-network

To understand the importance of verifying whether a provider participates in the ASA PPO network, it helps to understand how a PPO works and how to maximize the plan's benefits. 

Simply put, a PPO is a network of doctors, hospitals, and other health care providers who have been contracted by an insurance company or medical plan to provide care at a discount. The GHLIT PPO offers richer benefits and discounted fees for using ASA PPO network providers, and referrals are not required for visits to specialists.

While there may be many reasons to choose an in-network provider, doing so is not mandatory. Using an out-of-network provider, however, means giving up the PPO advantages, such as 80 percent coinsurance versus 60 percent coinsurance on PPO Value Plans, though the protection and provisions of the GHLIT major-medical coverage remain intact.

In fact, participants enrolled in any of the GHLIT medical plans, whether it's a PPO plan or a traditional plan, may benefit from using PPO network providers. Those benefits include lower out-of-pocket coinsurance payments when using network hospitals and reduced charges for other ASA network providers.  

Information resources

Although disruptions caused by the transition to the ASA PPO network are expected to be minimal, participants are likely to have questions. 

To help, responses to commonly asked questions are available on the GHLIT Web site. A pop-up screen provides direct links to the frequently asked questions section and to ASA's DocFind. Participants are also encouraged to call the Trust for further information on the PPO network, claims, or utilization review.

The AVMA GHLIT program is underwritten by New York Life Insurance Company (NY, NY 10010). For more information on AVMA GHLIT plans, including eligibility, rates, renewal provisions, exclusions, and limitations, or to find a GHLIT agent in a particular area, call the Trust office at (800) 621-6360.