Plan Amendment 2022-01

The 60-day public comment period regarding a proposed plan amendment to the AlaskaCare Defined Benefit Health Plan (Plan) is now closed. Thank you to those members that provided feedback!

Public Comment Log

2022 – Retiree Plan Amendment 2022-01

The Plan Administrator has reviewed the public comments and adopted the final Plan Amendment, which takes effect June 1, 2022. It is posted to the website and will be incorporated into the 2023 printed version of the Retiree Health Insurance Information Booklet.

FAQs

Are covered services being added or removed from the Plan as a result of this Amendment?

• No. The services covered by the Plan are not being expanded or altered as a result of this amendment. Rather, the proposed changes to Section 3.3.1 Medical Necessity clarify that, consistent with the Division’s historical practice:
  • Claims are initially evaluated for medical necessity according to the medical necessity standards outlined in the plan booklet and detail through the Claims Administrator’s clinical policy guidelines and bulletins, which are publicly available.
  • If a member disagrees with the Claims Administrator’s initial adjudication and coverage determination, the final decision as to whether a service is eligible for coverage under the terms of the plan rests with the Plan Administrator. The Plan Administrator’s evaluation of a claim occurs through the appeals process, specifically when a Third Level appeal is submitted to the Division.

The proposed language changes reiterate the factors that the Plan Administrator will consider when evaluating a claim.

Why is the Division proposing this Plan Amendment?

• The Retired Public Employees of Alaska, Inc. (RPEA) and the Division of Retirement and Benefits (Division) agreed to this amendment as part of the final settlement agreement negotiated to resolve two lawsuits: one related to the AlaskaCare retiree medical plan, and the other related to the AlaskaCare retiree dental-vision-audio plan.

What does the Plan Amendment do?
The amendment is intended to clarify certain parts of the Plan’s medical necessity provisions as follows:

• Confirms that as Plan Administrator, the Commissioner of Administration or their designee, has final authority to determine if a claim should be paid under the terms of the plan.
• Restates the factors that the Plan Administrator will consider when evaluating a claim. The Plan Administrator’s evaluation of individual claims occurs through the appeals process, specifically when a member reaches the third level appeal to the Division.

The amendment includes some additional changes, outlined below:

• Replaces the name of the current medical Claims Administrator (Aetna) with a neutral term (Claims Administrator), recognizing that the entity contracted to provide this service has, and will, change over time as the Division engages in competitive procurements.
• Provides a link to the Claims Administrator’s clinical policy bulletins at the front of the booklet.
• Defines “Plan Administrator,” “Claims Administrator,” and “Aetna.”
• Capitalizes “Plan Administrator” and “Claims Administrator” to reflect the added definitions.
• Provides lawsuits against the State arising from the plan may be brought in any judicial district in the State of Alaska.

What does “Plan Administrator” mean?

• The AlaskaCare Plan Administrator is the Commissioner of the Department of Administration. The Commissioner may identify a designee to act on their behalf as the Plan Administrator. For example, the Commissioner has, in the past, designated the Division of Retirement and Benefits to act as the Plan Administrator. The Plan Administrator is responsible for maintaining and managing the health care benefits available to AlaskaCare retirees. The Plan Administrator sets the terms of the Plan and has the final authority to determine what the Plan covers, and whether a claim or service is covered.

What does “Claims Administrator” mean?

• A Claims Administrator is a company that the Plan Administrator hires to assist with the operations of the health plan. The plan receives over 3 million medical, pharmacy, and dental claims per year, and the Division has always contracted with one or more Claims Administrators to process claims, make initial medical necessity determinations, and assist with day-to-day operations.
  Different Claims Administrators service different parts of the AlaskaCare plans. Currently, Aetna is the Claims Administrator for medical, vision, and audio claims, Optum Rx is the pharmacy Claims Administrator, and Delta Dental of Alaska administers dental claims.

Does the Settlement Agreement affect the protections against diminishment afforded by the Alaska Constitution?

• No. The Settlement Agreement with RPEA specifically provides that it shall not affect any protections afforded by the Alaska Constitution, Article XII, Duncan v. Retired Public Employees of Alaska, Inc., and/or State, Department of Administration v. The Retired Public Employees of Alaska, Inc.

Does this Plan Amendment change the current appeals process?

• No. The only proposed change to the current appeals process language is to capitalize “Plan Administrator.” All other appeals-related Plan language remains the same.

Does this Plan Amendment change my deductible?

• No. This Plan Amendment does not make any changes to member’s deductibles, copayments, or any other cost share provision.