Medical Plan

Submitted by mawills on
Introduction
The Carilion Clinic Medical Plan offers you the flexibility to see in-network or out-of-network providers and covers preventive care visits, such as annual checkups and screenings, at 100%, with no copay, deductible or coinsurance.
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About the Carilion Clinic Medical Plan

  • Providers (such as doctors, physician assistants or nurse practitioners) are designated as in-network or out-of-network.
  • Facilities (such as hospitals or urgent care centers) are designated as Level A, B or C. You will pay the lowest cost if you use Level A facilities. All Carilion facilities are included in Level A. Level B means the facility is not a Carilion facility but participates with Aetna. Level C means the facility is out-of-network and does not participate with the Aetna network.
  • Check Aetna's Custom DocFind before you receive medical services to confirm if your provider is in-network and which level the facility is in.
  • Preventive care visits, such as annual checkups and screenings, are always covered at 100 percent, with no copay, deductible or coinsurance.
  • Under Section 1557 of the Affordable Care Act (ACA), Carilion Clinic cannot provide employee health benefits in a discriminatory manner; therefore, we cannot take any of the following related actions if they differentiate on the basis of age, gender, race, color, national origin, language, culture, sexual orientation, gender identity and/or expression, pregnancy or disability:
    • Deny, cancel, limit or refuse to issue or renew an insurance policy;
    • Deny or limit coverage of a claim, or
    • Impose additional cost sharing or other limitations or restrictions
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Finding Providers
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  • Use Aetna’s custom DocFind tool to find providers.
  • All providers who are listed are in-network providers.
  • If you don’t see your provider listed, contact Aetna at 800-633-0635 to confirm the provider’s participation and level. The DocFind tool is updated frequently; be sure to check with Aetna before receiving services. 
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Using the Carilion Clinic Medical Plan
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  • The Carilion Clinic Medical Plan offers you the flexibility to see in-network or out-of-network providers. You will have lower out-of-pocket costs if you use an in-network provider and Level A hospital and facilities.  
  • In most cases, you will need to meet an annual deductible before the plan will pay for hospital and facility charges. A deductible is the amount you must pay before Aetna will begin making payments—it's like the deductible you pay if you make a claim on your auto insurance. 
    • For Level A facilities, the deductible is $800 for an individual and $1,600 for a family.
    • For Level B facilities, the deductible is $1,500 for an individual and $3,000 for a family.
    • For Level C facilities, the deductible is $3,000 for an individual and $6,000 for a family.
    • There is no deductible for in-network providers or pharmacy benefits.
  • After you meet the deductible, you will pay a combination of copays and coinsurance for most of your medical expenses. A copay is a set amount that you pay for a medical visit—for example, $20 to visit an in-network provider when you are sick. Coinsurance is a percentage of the cost of the visit that you pay. For example, when you visit a Level A facility, you pay 20 percent of the allowable cost of the visit. When you visit a Level B facility, you pay 40 percent of the allowable cost of the visit.
  • The plan has an out-of-pocket maximum charge. This means that once you have met the maximum amount, you will not be required to make any more payments out of your own pocket during the calendar year for any eligible expenses covered by the medical plan, including pharmacy expenses.
    • The out-of-pocket maximum for Carilion Clinic providers, Level A facilities and pharmacies is $4,000 for an individual and $8,000 for a family.
    • The out-of-pocket maximum for Level B in-network providers, facilities and pharmacies is $6,000 for an individual and $12,000 for a family.
    • The out-of-pocket maximum for out-of-network providers and Level C facilities are $9,000 for an individual and $18,000 for a family.
    • If you use providers and facilities from a combination of levels, you will need to meet the maximums for each level you use.
    • Deductibles, coinsurance and copays count toward the out-of-pocket maximum.
  • Present your Aetna ID card to your provider at the time of service.
  • Certain services, such as hospitalizations, may require pre-authorization from Aetna. Work with your physician to ensure that any necessary pre-authorizations are obtained before you receive services.
  • There are several mental health resources available for employees and family members. View this list of available options. 
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Setting Up an Online Account
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  • Visit www.Aetna.com and click "Register" under "Don't Have an Account?" and follow prompts to create an account.
  • Once you have an online account set up, you can download the Aetna mobile app, "Aetna Health" from the App Store. Review the Aetna Mobile App Flyer or watch this video for assistance on setting up the mobile app.
  • The mobile app gives you access to all your account details and a digital ID card to use anytime you're asked to show your medical insurance card.
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Preventive Examinations
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The Carilion Clinic Medical Plan is designed to support overall health and early detection of potential conditions by providing comprehensive coverage for preventive care services. 

Preventive visits—including routine wellness exams, annual physicals, immunizations, age-appropriate screenings, and other recommended preventive services—are typically covered at 100% when received from in-network providers. These services are intended to help identify health concerns early, promote healthy lifestyles, and reduce the need for more extensive treatment.


Covered preventive services may include, but are not limited to, annual check-ups, blood pressure and cholesterol screenings, cancer screenings (such as mammograms and colonoscopies), vaccinations, and other evidence-based services as recommended by national preventive care guidelines.

 

Routine Adult Physical Exams/Immunizations

  • 1 exam per calendar year for members aged 18 and older.

Routine Well Child Exams/Immunizations

  • 7 exams in first 12 months;
  • 3 exams in second 12 months;
  • 3 exams in third 12 months;
  • 1 exam per calendar year thereafter.

Routine Gynecological Care Exams

  • 1 exam per calendar year for 21 and older members.

Routine Mammogram

  • 1 baseline covered for ages 35-39;
  • 1 per calendar year for females age 40 and over.

Routine Digital Rectal Exam/Prostate – Specific Antigen Test

  • 1 annual DRE & PSA for males age 40 and older.

Lung Cancer Screening

  • 1 exam per calendar year for members 50 and older.

Routine Eye Exams

  • 1 routine eye exam per calendar year.
  • $15 copay for in-network providers.

Routine Hearing Exams

  • Covered with no age limits.

 

 

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Contact Information
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1095 Tax Information
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IMPORTANT HEALTH COVERAGE 1095 TAX DOCUMENTS 

According to Notice 2025-15 Carilion Clinic is no longer required to mail 1095 notices to eligible employees. The 1095 form shows whether we provided health insurance coverage for you and any of your dependents. 

Employee's may download a copy of their 1095 document from Workday. Once you log on to Workday, click the profile icon in the upper right-hand corner. Then select: View Profile>Actions>Benefits>View My ACA Forms. The select the "View/Print" option which will create a downloadable document that you can print or save.