PPO Medical Benefits | Health Connect

Understand your healthcare coverage.

About Your PPO Medical Benefits

The District offers Preferred Provider Organization (PPO) plans with varying levels of coverage. Utilizing the Aetna provider network, options include PPO Plan A and PPO Plan B for full-time employees and early retirees, and the Aetna Medicare Advantage PPO Plan for medicare-eligible retirees. The Aetna Open Choice PPO Plan is available to non-Medicare-eligible dependents of anyone who is enrolled in the Medicare Advantage PPO Plan.

Aetna PPO Coverage

With a Preferred Provider Organization (PPO) plan, you have greater flexibility and choice to use both in-network and out-of-network providers. However, you are encouraged to receive services from the Aetna network of doctors, specialists, and facilities. By doing so, you obtain a higher level of benefit than if services were rendered from an out-of-network provider. Also, claim forms are submitted to the plan on your behalf when services are received from within the network. Additional information regarding the use of a PPO plan includes:

You and any enrolled dependent(s) are permitted to visit any doctor or facility without a referral from a Primary Care Physician (PCP).
Certain services, such as doctor’s visits, may require fixed-dollar payment upfront, referred to as a copayment.
Before the plan will pay certain medical expenses, you may be required to pay a plan-specific amount, referred to as a deductible.
Once the deductible has been fulfilled, the plan will pay most, if not all (100%), of the cost of your in-network care, depending on your plan. This is known as coinsurance. You are then financially responsible for any remaining cost up to the out-of-pocket maximum, including copays.
A health plan physician must determine that the services and supplies are medically necessary to prevent, diagnose, or treat your medical condition. These services and supplies must be provided, prescribed, authorized, or directed by the health plan’s network physician or a non-network physician at different rates as specified by your benefits guide.

How to Find an Aetna Provider

Go to www.aetnaresource.com/p/FresnoUSD.
Scroll down and click on the “Find an Aetna Choice POS II Provider” purple button.
Within the “Continue as a guest” section, enter your location and click “Search.”
Type the name or type of provider you are looking for within the “What do you want to search for” section and press enter.
Sort through the provided list using the filters for results specific to your needs, such as language, gender preference, and provider type.

Note: It is important to use Aetna’s dedicated microsite for the District’s plan when searching for medical providers. The use of any other site, including Aetna.com, will provide inaccurate results based on our plan structure.

The following services and providers are NOT a part of the district’s PPO plan (but may be included in other areas of your total benefits coverage):

Acupuncture
Chiropractic
Dental
Pharmacy
Substance abuse
Sutter Health Systems providers
Vision

Annual Calendar Year Deductible

Generally, you must pay all of the costs from providers up to the deductible amount before your PPO plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Specific deductible amounts vary by plan and can be affected by whether a provider is in-network or out-of-network. More information about deductible amounts can be found in your Benefits packet.

Waiver of Annual Deductible for Dual-Covered PPO Plan Participants

The annual deductible is waived for all covered family members of a dual-covered member enrolled in PPO Plan Option A or PPO Plan Option B. To be eligible for this waiver, two District employees or retirees married to one another or in a domestic partnership must each enroll their spouse/domestic partner as a dependent under their plan.

Maximum Calendar Year Out-of-Pocket

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Specific out-of-pocket limits vary by plan and can be affected by whether a provider is in-network or out-of-network. More information about out-of-pocket amounts can be found in your Benefits packet.

Professional Services

Your Aetna PPO plan gives you flexibility in receiving basic health services, including primary care, diagnostics, specialists, and preventive care. These services are available to Aetna PPO Plan A, Aetna PPO Plan B, Aetna Medicare Advantage PPO, and Aetna Open Choice PPO plan members at various rates depending on your choice of in-network or out-of-network care. Learn more about the services listed below and their respective copays in your Benefits packet.

Primary Care Physician (PCP)
Specialist
Preventive Care Exam
Well-baby Care (first 5 years)
Diagnostic X-ray & Lab
Complex Diagnostics (MRI/CT Scan)
Therapy (Physical, Occupational, Speech)

Hospital & Emergency Services

Benefits increase for inpatient, outpatient, and urgent care services by staying in-network. However, you can still save on costs with out-of-network services. These services are available to Aetna PPO Plan A, Aetna PPO Plan B, Aetna Medicare Advantage PPO, and Aetna Open Choice PPO plan members at various rates depending on your choice of in-network or out-of-network care. Learn more about the services listed below and their respective copays in your Benefits packet.

Inpatient
Outpatient Surgery
Emergency Room
Urgent Care
Ambulance

Maternity Care

Your Aetna PPO plan gives you access to affordable pregnancy services and maternity support. These services are available to Aetna PPO Plan A, Aetna PPO Plan B, Aetna Medicare Advantage PPO, and Aetna Open Choice PPO plan members at various rates depending on your choice of in-network or out-of-network care. Learn more about the services listed below and their respective copays in your Benefits packet.

Physician Services
(Prenatal or Postnatal)
Hospital Services

Mental Health & Substance Abuse

If you are enrolled in PPO Plan A, PPO Plan B, Aetna Medicare Advantage PPO, or Aetna Open Choice PPO, your mental health and substance abuse coverage is through Simple Behavioral. Preauthorization is required for all mental health and substance abuse services. Your Aetna PPO plan gives you access to mental health and substance abuse services and support. These services are available to PPO plan members through Simple Behavioral at various rates depending on your choice of in-network or out-of-network care. Learn more about the services listed below and their respective copays in your Benefits packet.

Available Services Include:

Inpatient
Outpatient

Chiropractic & Acupuncture with Simple MSK

When you’re seeking relief from pain caused by an accident, injury, or muscle strain, or just looking for a natural healthcare approach, our Chiropractic and/or Acupuncture Benefits may be able to assist you. These benefits offered by Simple MSK provide you access to licensed professionals at a discounted rate.

Simple MSK provider with deductible waived
Non-Simple MSK provider allowed with conditions
Diagnostic X-Ray benefits available after deductible
Up to 28 Chiropractic visits per calendar year
Up to 20 Acupuncture visits per calendar year

Telehealth Services with Teladoc

Teladoc provides telehealth services for PPO Plans A & B. With Teladoc, you can connect with leading board-certified physicians in your state through the internet or telephone, helping you avoid emergency rooms and urgent care centers. Telehealth services are provided at no cost, and no deductible applies when using Teladoc. Teladoc can assist with prescription medications and with many non-emergency illnesses including:

Allergies
Arthritic pain
Asthma
Bronchitis
Colds and flu
Diarrhea
Insect bites
Pharyngitis
Conjunctivitis (pink eye)
Rash
Respiratory infection
Sinusitis
Skin inflammation
Sore throat
Sprains & strains
Urinary tract infection
Sports injuries
Vomiting

To access Teladoc, you can:

Download the Teladoc App (from the Apple App Store or Google Play Store)
Go online to www.Teladoc.com
Call 800.TELADOC (800.835.2362)

Frequently Asked Questions

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