Cornell Program for Healthy Living Addendum Effective January 1, 2016

Transcription

1 Cornell Program for Healthy Living Addendum Effective January 1, 2016 Addendum to the Cornell Program for Healthy Living Plan (CPHL) Summary Plan Description (SPD) The information below is intended to serve as an update to the 2014 Cornell Program for Healthy Living Plan (CPHL) Summary Plan Description (SPD) Effective January 1, 2016 The medical and prescription drug copays apply to the out of pocket maximum for in-network services. The plan includes all of the preventive care benefits mandated by the ACA. Below are the items revised or added for 2016: Eye exam (routine)-is now covered every year after copay Routine physical exam Age limit modified for CPHL: from age 19 changed to age 22 and up; Well Child age limit changed from birth to age 3 to birth to age 22 Preventive Care Covered at 100% In-network Routine Physical Exams Family Planning Tubal Ligation Obesity Preventive Counseling Tobacco Preventive Counseling Alcohol/Drug Abuse Counseling Preventive Lung Cancer Screening Colorectal Cancer Screening (ie colonoscopy) Routine PSA and DRE Routine GYN and Pap Routine mammography Lactation Consultation Contraceptive drugs and devices (except those covered by RX plan) including associated office visit (i.e. IUDs). Breast Pumps and supplies Contraceptive Consultation Routine eye exam (includes pediatric) is covered at 100% every (instead of every year). Prenatal care covered at 100% (delivery & nursery care remain covered at 90%). Breast Pumps and supplies OptumRx Prescription Drug Plan covers: Oral Contraceptives, barrier methods, OTC contraceptives, Plan B and ella (prescription required). Pre-natal maternity office visits OptumRx Prescription Drug Plan covers: Aspirin products, iron supplements, Vitamin D, Folic Acid & Prenatal Vitamins with prescription. This is only a brief summary of the Plan Features. Please refer to the Summary of Benefits and Plan Booklet for a complete description.

2 The Prescription Drug Plan is changing from Express Scripts (ESI) to OptumRx The copays are not changing and remain $5/$30/$50 for retail and $10/$60/$90 Home Delivery in-network The drug formulary is changing Some medications are excluded Home Delivery of maintenance medications/specialty medications can be delivered to your home address or new for 2016, you can direct the delivery to Gannett Health Center Pharmacy on the Ithaca campus. Briova is the specialty pharmacy replacing ESI s Accredo Aspirin products, iron supplements, Vitamin D, Folic Acid & Prenatal Vitamins with prescription covered at $0 copay (in-network) Effective April 1, 2015 Documentation Requirements Effective 4/1/15-copies only Employee: Social Security Card (or ITIN-Individual Taxpayer Identification Number for non- US Citizens). You must provide copies of documents to support your dependent s eligibility for coverage. Spouse or Domestic Partner: Birth Certificate (or Visa/Passport accepted for non-us citizens), Social Security Card (or ITIN-Individual Taxpayer Identification Number for non-us citizens), Marriage Certificate, Domestic Partner Statement Children (biological), stepchild, adopted: Birth Certificate (or Visa/Passport accepted for non- US citizens), Social Security Card, ITIN (Individual Taxpayer Identification Number) for non- US citizens, Proof of Disability, if applicable, Documentation establishing Paternity by Court Order acknowledging Paternity. If your child is neither of the above, you must also complete the Special Dependent Enrollment Form. Effective January 1, 2015 Express Scripts Prescription Drug Plan Changes Preferred Retail Pharmacy Network You pay $5/$30/$50 copay at retail for up to a 30 day supply if you use pharmacies participating in the Preferred Retail Pharmacy Network. Pharmacies include: Kinney, Rite Aid, Target, Walmart, Wegmans, Quilans, Green Street Pharmacy, Gannett Student Health Center, You pay $15/$40/$60, if you use CVS/Walgreens (Duane Reed), pharmacies not participating. Aetna CPHL Addendum 1/1/16

3 Exclusionary Formulary: Certain medications that are available as generics or on the formulary are no longer covered as of 1/1/15. Members can appeal and ESI will review the clinical information provided by the physician. Social Security s Definition of a Spouse. As of January 1, 2015, the Social Security s definition of spouse has expanded to include a same-sex spouse for the purpose of determining Medicare primacy. Therefore, an active employee s same-sex spouse, age 65 or older, will be Aetna primary not Medicare primary. Certificates of Creditable Coverage (HIPAA Certs) No Longer Required The Affordable Care Act prohibits the use of pre-existing condition clauses resulting in the need to provide certificates of creditable coverage no longer necessary. On February 24, 2014, the Treasury, the Department of Labor, and the Department of Health and Human Service jointly issued final regulations which eliminated the requirement for plan sponsors to issue the certificates after 12/31/14. Grandfathered Health Plan Notice for January 1, 2015 Cornell University believes your plan is a grandfathered health plan under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to your employer or Aetna member services using the phone number on your member id card. If your plan is governed by ERISA, you may also contact the Employee Benefits Security Administration, U.S. Department of Labor at or HUwww.dol.gov/ebsa/healthreformUH. This website has a table summarizing which protections do and do not apply to grandfathered health plans. If your plan is a nonfederal governmental plan, you may also contact the U.S. Department of Health and Human Services at HUwww.healthreform.govUH. Aetna CPHL Addendum 1/1/16

4 Schedule of Benefits Employer: Cornell University ASC: Issue Date: July 1, 2014 Effective Date: January 1, 2014 Schedule: 8A Booklet Base: 8 For: Cornell Program for Healthy Living This is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information. Aetna Choice POS II Medical Plan PLAN FEATURES Calendar Year Deductible* CPHL ENHANCED WELLNESS AND IN- NETWORK **OUT-OF-NETWORK Individual Deductible* None $400 Family Deductible* Once family deductible is met, all family members will be considered as having met their deductible for the remainder of the Calendar Year None $800 * Unless otherwise indicated, any applicable deductible must be met before benefits are paid. ** Subject to Recognized Charge The Maximum Out of Pocket Limit includes plan deductible. The Maximum Out of Pocket Limit excludes precertification penalties, copayments, expenses paid at 50%, non-covered expenses and charges over the recognized charge. Individual Maximum Out of Pocket Limit: For network expenses: $2,000. For out-of-network expenses: $3,500. Family Maximum Out of Pocket Limit: For network expenses: $4,000. For out-of-network expenses: $7,000. Lifetime Maximum Benefit per Person Unlimited Unlimited 1

5 How the Cornell Program for Healthy Living Works The Cornell Program for Healthy Living (CPHL) is a new comprehensive health plan that encourages and facilitates your progress to healthier living. This is achieved by focusing on your total health through an Enhanced Wellness Program. There are two components: the underlying Medical Plan and the Enhanced Wellness Program. Highlights of the Medical Plan (Choice POSII) Level of Health Plan Support PCP Requirement In-Network Higher so you pay less out of pocket: No Deductible $20 office visit copay 90% for other services Pharmacy is administered by Express Scripts/Medco. Applies to enhanced wellness benefit only (see back page for details). Out-of-Network Lower so you pay more out of pocket: $400 deductible 80% thereafter Pharmacy is administered by Express Scripts/Medco. N/A Referral Requirement to a Specialist No referrals needed. No referrals needed. Preventive Care Broad National Network of Physicians and Hospitals Balance Billing (the amount billed by your provider that is over the insurance company s allowed amount) Certification for Inpatient Hospital and Other Medical Services Covered at 100%, regardless of where you live and the network PCP you choose. Fully available at discount prices. Providers have agreed not to bill you over allowed amount. Participating provider precertifies for you. Covered at 80% after deductible. You may use out-of-network providers but it will cost you more. Providers are free to bill you over the allowed amount. You precertify by calling the toll-free number on your ID card. Failure to precertify may result in substantially reduced benefits. Claim Forms to File No. Yes. 2

6 The Enhanced Wellness Program The Enhanced Wellness Benefits are available only if you chose to utilize a PCP from a select list of Ithaca based In- Network Providers. Please note: there is NO PCP selection required if you and your family members elect not to take part in the Enhanced Wellness Exam and related services. Step 1 To Receive an Enhanced Wellness Exam Select a PCP Step 2 Schedule Physical Exam and Lab Work Step 3 Complete a Sustainable Health Questionnaire SHQ/HRA Step 4 Comprehensive Exam and Wellness Report Step 5 The Healthy Living Wellness Resources All covered family members, including children, must select a PCP from a select list of Ithaca based In-Network providers if you would like to take advantage of the Enhanced Wellness Program. These PCPs have committed to support this plan and a play a pivotal role in helping you reach your wellness goals for the year. You can select your PCP at the time of enrollment through Benefit Services, or after enrollment through Aetna Navigator or by calling Aetna Member Services at You can find the names of the Ithaca based PCP s at You and your enrolled adult family members (spouse, domestic partner and children ages 1and over) schedule annual comprehensive physical exam(s) and lab work with your Enhanced Wellness PCP unless otherwise directed by your PCP. Your comprehensive exam and routine lab work are covered at 100%. You and your enrolled adult family members (spouse, domestic partner and children ages 18 and over) will complete a Sustainable Health Questionnaire (SHQ)/Health Risk Assessment (HRA) once a year. This SHQ/HRA must be completed no more than one week prior to your annual comprehensive physical exam with your PCP. Children age 1 through 17 will complete a pediatric assessment in their PCP s office. Once you have completed your SHQ/HRA, you are ready for a comprehensive physical exam and a review of your SHQ results with your Enhanced Wellness PCP. There is no cost to you. Once the exam and review have been completed, your PCP will provide you with an Annual Wellness Report from which you and your PCP will develop a healthy living action plan. Your Wellness Report and healthy living action plan may include referrals to local resources, or to additional services within your PCP s office, to assist you in achieving your goals. These additional services for smoking cessation, nutritional counseling and diabetic education are covered at 100%. In addition, if you have medical complications or need special attention, your PCP may refer you to the Cayuga Center for Healthy Living (CCHL) for advanced wellness counseling and support for the following services. The costs for these services at CCHL are Health Behavior Assessment Health Risk Assessment Interpretation Medically Supervised Exercise Team Conference Preventive Medical Counseling Stress Management $20 copay $20 copay $20 copay $20 copay $20 copay $20 copay Faculty and Staff are also eligible to receive a $15 monthly discount from either the Ithaca YMCA, Island Fitness or the Cornell Wellness Program (the discount makes the Cornell Wellness free). Spouses and domestic partners who are Cornell employees are eligible if they are covered under CPHL. The CPHL Aetna ID Card and Cornell ID are required to be presented to the fitness centers to confirm eligibility for the discount. Step 6 Follow-up Visits Following your Enhanced Wellness exam, your PCP may decide to have you return for up to 3 monitoring or counseling check-ups during the year. These extra visits are also covered at 100% under the Enhanced Wellness benefit. You are strongly encouraged to see your Enhanced Wellness PCP at least once every year to complete steps 2-5 above unless otherwise directed by your PCP. 3

7 Payment Percentages listed in the Schedule below reflects the Plan Payment Percentage. This is the amount Aetna pays. You are responsible to pay any deductibles, copayments, and the remaining payment percentage. You are responsible for full payment of any non-covered expenses you incur. Covered Expenses That Are Subject To The Calendar Year Deductible Are Noted In The Schedule Below. * The In-Network benefit level includes medically necessary care provided out of the country. PLAN FEATURES Wellness Benefit Routine Physical Exams Adults only. Includes coverage for immunizations. CPHL ENHANCED WELLNESS 100% including lab and x-ray IN-NETWORK* 100% including lab and x-ray OUT-OF-NETWORK 80% per exam after Maximum Exams per Calendar Year Adults age 18 and over 1 exam plus 3 follow up preventive visits 1 exam 1 exam Well Child Exams Includes coverage for immunizations 100% including lab and x-ray 100% including lab and x-ray 80% per exam after Maximum Exams Under age 3 first 12 months of life 7 exams 7 exams 7 exams 13 th 24 th months of life 4 exams 3 exams 3 exams 25 th 36 th months of life 4 exams 3 exams 3 exams For age 3 to 18 4 exams 1 exam 1 exam Immunizations when not part of the physical exam Same as In-Network 100% 80% per visit after Screening & Counseling Services - Obesity, Misuse of Alcohol and/or Drugs & Use of Tobacco Products 100% per visit 100% per visit 80% per visit after Nutritional Counseling other than Screening & Counseling Services for Obesity 100% per visit $20 per visit copay then 80% per visit after the plan pays 100% in an office setting; otherwise 90% 4

8 Obesity Maximum Visits per Calendar Year (This maximum applies only to Covered Persons ages 18 and older.) Unlimited 26 visits (however, of these 26 visits (however, of these only 10 visits will be only 10 visits will be allowed under the Plan for allowed under the Plan for healthy diet counseling healthy diet counseling provided in connection with provided in connection with Hyperlipidemia (high Hyperlipidemia (high cholesterol) and other cholesterol) and other known risk factors for known risk factors for cardiovascular and cardiovascular and diet-related chronic disease* diet-related chronic disease* *Note: In figuring the Maximum Visits, each session of up to 60 minutes is equal to one visit. Nutritional Counseling other than for Obesity Maximum Visits per Unlimited Based on Medical Based on Medical Calendar Year Necessity Necessity Use of Tobacco Products Maximum Visits per Calendar Year Unlimited 8 visits* 8 visits* *Note: In figuring the Maximum Visits, each session of up to 60 minutes is equal to one visit. Misuse of Alcohol and/or Drugs Maximum Visits per Calendar Year Unlimited 5 visits* 5 visits* *Note: In figuring the Maximum Visits, each session of up to 60 minutes is equal to one visit. PLAN FEATURES CPHL ENHANCED WELLNESS IN-NETWORK OUT-OF-NETWORK Routine Cancer Screenings Routine Mammography Same as In-Network 100% 80% per test after Maximum tests per Calendar Year 1 test 1 test 1 test Prostate Specific Antigen Test For covered males age 40 and over. 100% per test 100% 80% per test after Maximum tests per Calendar Year 1 test 1 test 1 test 5

9 Routine Digital Rectal Exam For covered males age 40 and over. 100% per test 100% 80% per test after Maximum tests per Calendar Year 1 test 1 test 1 test Fecal Occult Blood Test Same as In-Network 100% 80% per test after Maximum tests per Calendar Year 1 test 1 test 1 test Sigmoidoscopy Age 50 and over Same as In-Network 100% 80% per test after Maximum Tests per 5 consecutive year period 1 test 1 test 1 test Double Contrast Barium Enema (DCBE) Age 50 and over Same as In-Network 100% 80% per test after Maximum Tests per 5 consecutive year period 1 test 1 test 1 test Colonoscopy age 50 and over 1 test 100% 80% per test after Maximum Tests per 10 consecutive year period 1 test 1 test 1 test 6

10 All Other Routine Exams and Screenings Same as In-Network 100% 80% per test after Maximum per Calendar Year Subject to any age and visit limits provide for in the current recommendations of the United States Preventive Services Task Force and comprehensive guidelines supported by the Health Resources and Services Administration Same Same For details, contact your physician, log onto the Aetna website or call the number on the back of your ID card. PLAN FEATURES CPHL ENHANCED WELLNESS IN-NETWORK OUT-OF-NETWORK Well Woman Preventive Visits Routine Gynecological Exam (Including Routine Pap Smears) Same as In-Network 100% 80% per exam / test after Maximum per Calendar Year 1 exam 1 exam 1 exam Prenatal Visits Same as In-Network 100% 80% per exam after PLAN FEATURES CPHL ENHANCED WELLNESS IN-NETWORK Comprehensive Lactation Support and Counseling Services Lactation Consultation Same as In-Network 100% for the first 6 visits per year. $20 copay thereafter OUT-OF-NETWORK 80% per visit after Breast Pump and Supplies Electric Breast Pump 1 service maximum in 36 months Same as In-Network 100% 80% after Calendar Year deductible 7

11 PLAN FEATURES Family Planning Services Family Planning Services: Contraception, Voluntary Sterilization and Abortion CPHL ENHANCED WELLNESS Same as In-Network IN-NETWORK 90% Vasectomy and Abortion. 100% for Tubal Ligation; includes associated ancillary services and contraceptive services OUT-OF-NETWORK 80% after Calendar Year deductible. Includes Voluntary Sterilization, Voluntary Abortion and contraceptive services. PLAN FEATURES CPHL ENHANCED WELLNESS IN-NETWORK Vision Care Eye Examinations Same as In-network $20 exam copay then the plan pays 100% OUT-OF-NETWORK 80% per exam after Maximum Benefit per every two calendar years 1 exam 1 exam 1 exam PLAN FEATURES CPHL ENHANCED WELLNESS IN-NETWORK Hearing Care Routine Hearing Exam Same as In-network $20 exam copay then the plan pays 100%; 100% for hearing exam performed by PCP OUT-OF-NETWORK 80% per exam after Maximum exams per every two calendar years Same as In-network 1 exam 1 exam Hearing aids Same as In-network 90% 80% after Calendar Year deductible child age 12 and under once every two calendar years adults and children age 13 once every four calendar years $1,500 max per aid per ear Excludes batteries and repairs 8

12 PLAN FEATURES Physician Services Office Visits to Primary Care Physician Office visits (non-surgical) to non-specialist CPHL ENHANCED WELLNESS IN-NETWORK OUT-OF-NETWORK Same as In-Network $20 per visit copay then 80% per visit after the plan pays 100% Specialist Office Visits Same as In-Network $20 per visit copay then 80% per visit after the plan pays 100% Physician Office Visits- Surgery Same as In-Network $$20 per visit copay then 80% per visit after the plan pays 100% Walk-In Clinics Non- Emergency Visit Same as In-Network $20 per visit copay then 80% per visit after the plan pays 100% Physician Services for Inpatient Facility and Hospital Visits Same as In-Network 90% per visit 80% per visit after Administration of Anesthesia Same as In-Network 90% per procedure 80% per procedure after Allergy Testing and Treatment Same as In-Network $20 exam copay then the plan pays 100% 80% per exam after Allergy Injections Same as In-Network 90% per procedure 80% per procedure after 9

13 PLAN FEATURES Emergency Medical Services Hospital Emergency Facility and Physician CPHL ENHANCED WELLNESS IN-NETWORK OUT-OF-NETWORK Same as In-Network 90% per visit 90% per visit Non-Emergency Care in a Hospital Emergency Room Same as In-Network 50% per visit 50% per visit after Urgent Care Services Urgent Medical Care (at a non-hospital free standing facility) Same as In-Network 90% 80% after Calendar Year deductible Non-Urgent Use of Urgent Care Provider (at a non-hospital free standing facility) Not covered Not covered Not covered PLAN FEATURES CPHL ENHANCED WELLNESS IN-NETWORK OUT-OF-NETWORK Diagnostic X-rays (except complex imaging services) Same as In-Network 90% per procedure 80% per procedure after Complex Imaging Services Complex Imaging Same as In-Network 90% per test 80% per test after Calendar Year deductible Diagnostic Laboratory Testing Diagnostic Laboratory Testing Same as In-Network 90% per procedure 80% per procedure after 10

14 PLAN FEATURES CPHL ENHANCED WELLNESS IN-NETWORK OUT-OF-NETWORK Outpatient Surgery Performed in a Physician s Office Same as In-Network $20 per visit/surgical procedure copay then the plan pays 100% 80% per visit/surgical procedure after Calendar Year deductible Performed at a Hospital Outpatient Facility Same as In-Network 90% per visit/surgical procedure 80% per visit/surgical procedure after Calendar Year deductible Performed at any other Facility Same as In-Network 90% per visit/surgical procedure 80% per visit/surgical procedure after Calendar Year deductible PLAN FEATURES CPHL ENHANCED WELLNESS IN-NETWORK OUT-OF-NETWORK Inpatient Facility Expenses Birthing Center Same as In-Network 90% per admission 80% per admission after Hospital Facility Expenses Room and Board (including maternity) Same as In-Network 90% per admission 80% per admission after Other than Room and Board Same as In-Network 90% per admission 80% per admission after Skilled Nursing Inpatient Facility Same as In-Network 90% per admission 80% per admission after Maximum Days per Calendar Year Same as In-Network 90 days 90 days 11

15 PLAN FEATURES Specialty Benefits Home Health Care (Outpatient) CPHL ENHANCED WELLNESS IN-NETWORK OUT-OF-NETWORK Same as In-Network 90% per visit 80% per visit after Maximum Visits per Calendar Year 120 visits 120 visits 120 visits Private Duty Nursing (Outpatient) Same as In-Network 90% per visit 80% per visit after Maximum Visit Limit per Calendar Year Same as In-Network 70 Private Duty Nursing Shifts. Eight (8) hours equal one shift. 70 Private Duty Nursing Shifts. Eight (8) hours equal one shift. Hospice Benefits Hospice Care - Facility Expenses (Room & Board) Hospice Care - Other Expenses during a stay Same as In-Network 100% per admission 80% per admission after Same as In-Network 100% per admission 80% per admission after Maximum Benefit per lifetime Unlimited Unlimited Unlimited Hospice Outpatient Visits Same as In-Network 100% per visit 80% per visit after Maximum Benefit per lifetime Unlimited Unlimited Unlimited 12

16 PLAN FEATURES CPHL ENHANCED WELLNESS IN-NETWORK OUT-OF-NETWORK Infertility Treatment Basic Infertility Expenses Coverage is for the diagnosis and treatment of the underlying medical condition causing the infertility only. Same as In-Network $20 per visit / test copay then the plan pays 100% in office setting; otherwise 90% 80% per visit / test after Advanced Reproductive Technology (ART) Expenses or Artificially Assisted Fertilization The AAF benefit is a limited provision expressed as a lifetime maximum dollar amount that applies to all endowed health plans one may join over time. The lifetime maximum benefit limit is $20,000 per household, meaning that the maximum lifetime benefit will not be provided more than once to an employee's household, regardless of how that household may change over time or the number of Cornell employees in the household. Same as In-Network 90% per visit 80% per visit after $20,000 $20,000 $20,000 CPHL ENHANCED PLAN FEATURES WELLNESS Inpatient Treatment of Mental Disorders MENTAL DISORDERS Hospital Facility Expenses IN-NETWORK OUT-OF-NETWORK Room and Board Same as In-Network 90% per admission 80% per admission after Other than Room and Board Same as In-Network 90% per admission 80% per admission after Physician Services Same as In-Network 90% per admission 80% per admission after 13

17 Inpatient Residential Treatment Facility Expenses Same as In-Network 90% per admission 80% per admission after Inpatient Residential Treatment Facility Expenses Physician Services Same as In-Network. 90% per visit 80% per visit after Outpatient Treatment Of Mental Disorders Outpatient Services Same as In-Network $20 per visit copay then the plan pays 100% 80% per visit after CPHL ENHANCED PLAN FEATURES IN-NETWORK WELLNESS Inpatient Treatment of Alcoholism and Substance Abuse Hospital Facility Expenses OUT-OF-NETWORK Room and Board Same as In-Network 90% per admission 80% per admission after Other than Room and Board Same as In-Network 90% per admission 80% per admission after Physician Services Same as In Network 90% per admission 80% per admission after Inpatient Residential Treatment Facility Expenses Inpatient Residential Treatment Facility Expenses Physician Services Same as In-Network 90% per admission 80% per admission after. Same as In-Network 90% per visit 80% per visit after Outpatient Treatment of Substance Abuse Outpatient Treatment Same as In-Network $20 per visit copay then the plan pays 100% 80% per visit after 14

18 CPHL ENHANCED PLAN FEATURES WELLNESS Obesity Treatment Surgical and Non Surgical Outpatient Obesity Treatment (non surgical) IN-NETWORK OUT-OF-NETWORK Same as In-Network 90% per visit 80% per visit after Inpatient Morbid Obesity Surgery (includes Surgical procedure and Acute Hospital Services) Same as In-Network 90% per admission 80% per admission after Related Outpatient Morbid Obesity Surgery Services Same as In-Network 90% per service 80% per service after Autism Spectrum Disorder Please refer to Aetna s Clinical Policy Bulletin for a more complete list of covered services and any applicable exclusions: PLAN FEATURES CPHL ENHANCED WELLNESS IN-NETWORK Office Visits Same as In-Network $20 per visit copay then the plan pays 100% OUT-OF-NETWORK 80% per visit after. Outpatient Treatment of Mental Disorders (includes applied behavioral analysis and behavioral therapy) Same as In-Network $20 per visit copay then the plan pays 100% 80% per visit after. Short Term Outpatient Rehabilitation Therapies Outpatient Physical, Occupational and Speech Therapy combined Maximum Visit Limit per Calendar Year for Speech Therapy only Same as In-Network 90% per visit 80% per visit after Same as In-Network 50 visits 50 visits 15

19 Transgender Reassignment (Sex Change) Surgery Covered expenses include charges in connection with a medically necessary Transgender Reassignment (sometimes called Sex Change) Surgery as long you or a covered dependent have obtained precertification from Aetna. Please refer to the Benefit Plan Booklet for additional information. You can also refer to Aetna s Clinical Policy Bulletin for a more complete list of covered services and any applicable exclusions: PLAN FEATURES Inpatient Hospital Transgender Reassignment Surgery CPHL ENHANCED WELLNESS IN-NETWORK OUT-OF-NETWORK Same as In-Network 90% per admission 80% per admission after Office Visits (includes surgery performed in the office) Same as In-Network $20 per visit / surgical procedure copay then the plan pays 100% 80% per visit/surgical procedure after Calendar Year deductible. Outpatient Treatment of Mental Disorders Same as In-Network $20 per visit copay then the plan pays 100% 80% per visit after. Short Term Outpatient Rehabilitation Therapies Outpatient Physical, Occupational and Speech Therapy combined Maximum Visit Limit per Calendar Year for Speech Therapy only Same as In-Network 90% per visit 80% per visit after Same as In-Network 50 visits 50 visits Transplant Services Facility and Non-Facility Expenses PLAN FEATURES NETWORK NETWORK (IOE Facility) (Non-IOE Facility) OUT-OF-NETWORK Facility Expenses 90% per admission 90% per admission 80% per admission after Physician (including office visits) 90% per admission 90% per admission 80% per admission after 16

20 CPHL ENHANCED PLAN FEATURES WELLNESS Other Covered Health Expenses IN-NETWORK OUT-OF-NETWORK Acupuncture in-lieu of anesthesia Same as In-Network $20 copay per service then the plan pays 100% in office setting; otherwise 90% 80% per service after Ground, Air or Water Ambulance Same as In-Network 90% 90% Durable Medical and Surgical Equipment Same as In-Network 90% per item 80% per item after Oral and Maxillofacial Treatment (Mouth, Jaws and Teeth) Same as In-Network $20 copay per service then the plan pays 100% in office setting; otherwise 90% 80% per service after Prosthetic Devices Same as In-Network $20 copay per item then the plan pays 100% in office setting; otherwise 90% 80% per item after 17

21 PLAN FEATURES Outpatient Therapies CPHL ENHANCED WELLNESS IN-NETWORK OUT-OF-NETWORK Chemotherapy Performed in a Physician's Office or Home Care Same as In-Network $20 per visit copay then the plan pays 100% 80% per visit after Performed in a Hospital Outpatient Department or Non-Hospital Outpatient Facility Same as In-Network 90% per visit 80% per visit after Infusion Therapy (Performed in a Physicians Office or Home Care) Same as In-Network $20 per visit copay then the plan pays 100% 80% per visit after Performed in a Hospital Outpatient Department or Non-Hospital Outpatient Facility Same as In-Network 90% per visit 80% per visit after Radiation Therapy Performed in a Physician's Office or Home Care Same as In-Network $20 per visit copay then the plan pays 100% 80% per visit after Performed in a Hospital Outpatient Department or Non-Hospital Outpatient Facility Same as In-Network 90% per visit 80% per visit after CPHL ENHANCED PLAN FEATURES WELLNESS Short Term Outpatient Rehabilitation Therapies IN-NETWORK OUT-OF-NETWORK Outpatient Physical and Occupational Therapy only Same as In-Network 90% per visit 80% per visit after Autism Outpatient Physical and Occupational Therapy only Same as In-Network 90% per visit 80% per visit after Speech Therapy only Same as In-Network 90% per visit 80% per visit after Autism Speech Therapy only Same as In-Network 90% per visit 80% per visit after 18

22 Speech Therapy Maximum visits per Calendar Year combined Same as In-Network 50 visits 50 visits Autism Behavioral Therapy Same as In-Network 90% per visit 80% per visit after PLAN FEATURES Spinal Manipulation (Chiropractor) CPHL ENHANCED WELLNESS Same as In-Network IN-NETWORK $20 per visit copay then the plan pays 100% OUT-OF-NETWORK 80% per visit after Expense Provisions The following provisions apply to your health expense plan. This section describes cost sharing features, benefit maximums and other important provisions that apply to your Plan. The specific cost sharing features and the applicable dollar amounts or benefit percentages are contained in the attached health expense sections of this Schedule of Benefits. This Schedule of Benefits replaces any Schedule of Benefits previously in effect under your plan of health benefits. KEEP THIS SCHEDULE OF BENEFITS WITH YOUR BOOKLET. Deductible Provisions Out-of-Network Calendar Year Deductible Individual This is an amount of out-of-network covered expenses incurred each Calendar Year for which no benefits will be paid. The out-of-network applies separately to you and each of your covered dependents. After covered expenses reach the out-of-network, the plan will begin to pay benefits for covered expenses for the rest of the Calendar Year. Family Deductible Limit When you and each of your covered dependents incur covered expenses that apply towards the individual Calendar Year deductibles, these expenses will also count toward a family deductible limit. To satisfy this family deductible limit for the rest of the Calendar Year, the following must happen: The combined covered expenses that you and each of your covered dependents incur towards the individual s must reach this family deductible limit in a Calendar Year. When this occurs in a Calendar Year, the individual s for you and your covered dependents will be considered to be met for the rest of the Calendar Year. 19

23 Copayments and Benefit Deductible Provisions Copayment, Copay This is a specified dollar amount or percentage of the negotiated charge required to be paid by you at the time you receive a covered service from a network provider. It represents a portion of the applicable expense. Payment Provisions Payment Percentage This is the percentage of your covered expenses that the plan pays and the percentage of covered expenses that you pay. The percentage that the plan pays is referred to as the Plan Payment Percentage. Once applicable deductibles have been met, your plan will pay a percentage of the covered expenses, and you will be responsible for the rest of the costs. The payment percentage may vary by the type of expense. Refer to your Schedule of Benefits for payment percentage amounts for each covered benefit. Maximum Out-of-Pocket Limit The Maximum Out-of-Pocket Limit is the maximum amount you are responsible to pay for covered expenses during the Calendar Year. This Plan has an individual Maximum Out-of-Pocket Limit. As to the individual Maximum Out-of-Pocket Limit, each of you must meet your Maximum Out-of-Pocket Limit separately and they cannot be combined and applied towards one limit. Certain covered expenses do not apply toward the Maximum Out-of-Pocket Limit. See list below. Network Provider Maximum Out-of-Pocket Limit Individual Once the amount of eligible network provider expenses you or your covered dependents have paid during the Calendar Year meets the individual Maximum Out-of-Pocket Limit, this Plan will pay 100% of such covered expenses that apply toward the limit for the remainder of the Calendar Year for that person. Family Maximum Out-of-Pocket Limit When you and each of your covered dependents incur covered expenses that apply towards the individual Calendar Year network provider Maximum Out-of-Pocket Limit, these expenses will also count toward a family network provider Maximum Out-of-Pocket Limit. To satisfy this family network provider Maximum Out-of-Pocket Limit for the rest of the Calendar Year, the following must happen: The family Maximum Out-of-Pocket Limit is a cumulative Maximum Out-of-Pocket Limit for all family members. The family network provider Maximum Out-of-Pocket Limit can be met by a combination of family members with no single individual within the family contributing more than the individual network provider Maximum Out-of-Pocket Limit amount in a Calendar Year. Out-of Network Provider Maximum Out-of-Pocket Limit Individual Once the amount of eligible out-of-network provider expenses you or your covered dependents have paid during the Calendar Year meets the individual Maximum Out-of-Pocket Limit, this Plan will pay 100% of such covered expenses that apply toward the limit for the remainder of the Calendar Year for that person. 20

24 Family Maximum Out-of-Pocket Limit When you and each of your covered dependents incur covered expenses that apply towards the individual Calendar Year out-of-network provider Maximum Out-of-Pocket Limit, these expenses will also count toward a family outof-network provider Maximum Out-of-Pocket Limit. To satisfy this family out-of-network provider Maximum Out-of-Pocket Limit for the rest of the Calendar Year, the following must happen: The family Maximum Out-of-Pocket Limit is a cumulative Maximum Out-of-Pocket Limit for all family members. The family out-of-network provider Maximum Out-of-Pocket Limit can be met by a combination of family members with no single individual within the family contributing more than the individual out-of- network provider Maximum Out-of-Pocket Limit amount in a Calendar Year. The Maximum Out-of-Pocket Limit applies to both network and out -of-network benefits. Covered expenses applied to the out-of-network Maximum Out-of-Pocket Limit will be applied to satisfy the in-network Maximum Out-of-Pocket Limit and covered expenses applied to the in-network Maximum Out-of-Pocket Limit will be applied to satisfy the out-of-network Maximum Out-of-Pocket Limit. Expenses That Do Not Apply to Your Out-of-Pocket Limit Certain covered expenses do not apply toward your plan out-of-pocket limit. These include: Charges over the recognized charge; Expenses to which a copayment is applied; Expenses incurred for outpatient prescription drugs. Non-covered expenses; Certain other covered expenses (see list in the Schedule of Benefits), and Expenses that are not paid, or precertification benefit reductions because a required precertification for the service(s) or supply was not obtained from Aetna. Any covered expenses which are payable by Aetna at 50%. Precertification Benefit Reduction The Booklet contains a complete description of the precertification program. Refer to the Understanding Precertification section for a list of services and supplies that require precertification. Failure to precertify your covered expenses when required will result in a benefits reduction as follows: A $400 benefit reduction will be applied separately to each type of expense. General This Schedule of Benefits replaces any similar Schedule of Benefits previously in effect under your plan of benefits. Requests for coverage other than that to which you are entitled in accordance with this Schedule of Benefits cannot be accepted. This Schedule is part of your Booklet and should be kept with your Booklet. 21

25 Plan Features for Prescription Drug Prescription Drug Services Plan Features Express Scripts (ES) Three-Tier Prescription Drug Plan for Endowed Faculty and Staff Effective January 1, 2014 Tier One: Tier Two: Tier Three: Local Participating Pharmacies (including insulin; generics required when available) Covered generic drugs Covered brand-name drugs on ES Formulary Covered brand-name drugs not on ES Formulary In-Network Coverage (Preferred Benefit Level) Tier 1: $5; Tier 2: $30; Tier 3: $50. Up to 30 day supply ES Home Delivery Tier 1: $10; Tier 2: $60; Tier 3: $90. Up to 90 day supply renewable up to a year for home delivery Out-of-Network Coverage (Non-Preferred Benefit Level) Reimbursed 100% of the ES negotiated rate, less the applicable copay Not covered Prescription Contraceptives CPHL CPHL Aetna PPO, Aetna HSA, Aetna 80/20 Aetna PPO, Aetna HSA, Aetna 80/20 Barrier methods (i.e. diaphragm) Oral contraceptives Over the Counter Contraceptives: Female condom, sponge, spermicide, Plan B and ella (Prescription required) In-Network $0 copay for generic or single source brand*+ $0 copay for generic or single source brand*+ $0 copay for generic or single source brand*+ Out of Network Reimbursed 100% of the ES negotiated rate, less applicable copay*+ Reimbursed 100% of the ES negotiated rate, less applicable copay*+ Reimbursed 100% of the ES negotiated rate, less applicable copay*+ In-Network Refer to the above ES Tier Schedule Refer to the above ES Tier Schedule Not Covered Out of Network Refer to the above ES Tier Schedule Refer to the above ES Tier Schedule Not Covered *If not a generic or single source brand, refer to the above ES tier schedule for the 2 nd or 3 rd tier copays. + If your doctor determines that the generic or single source contraceptive would be medically inappropriate, they can prescribe a medically appropriate multisource contraceptive. Note: Contraceptives that are injectable or implantable continue to be covered under the Aetna medical plans as part of the office visit. Under CPHL, the visit is covered at 100% in-network. 22

26 Please note: Certain medications require prior authorization or are subject to quantity limits. Call ES s Member Services at (800) or log on to If you are a firsttime user, you will need to register and provide your member ID number listed on your ES ID card. To access the ES Formulary on the ES Website: 1. Visit: and log in. 2. Select Clients (on the left side of the screen) 3. Scroll to the bottom and click on interactive Preferred Prescriptions Formulary Tool 4. Enter medication name (minimum of four (4) letters required, then click on Search 5. The drug name, available dosage, formulary status and whether the drug is generic or brand name will be provided. 6. Contact ES at (800) with questions. 23

27 Grandfathered Health Plan Notice Plan Sponsor Name: Cornell University Cornell University considers your plan a grandfathered health plan under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to your employer or Aetna member services using the phone number on your member id card. Your plan is governed by ERISA, so you may also contact the Employee Benefits Security Administration, U.S. Department of Labor at or This website has a table summarizing which protections do and do not apply to grandfathered health plans. 24

28 BENEFIT PLAN Prepared Exclusively for Cornell University What Your Plan Covers and How Benefits are Paid Cornell Program for Healthy Living for Active Employees, Under 65 Retirees and Dependents

29 Table of Contents Preface...2 Important Information Regarding Availability of Coverage Coverage for You and Your Dependents...3 Health Expense Coverage...3 Treatment Outcomes of Covered Services When Your Coverage Begins...4 Who Can Be Covered...4 Employees Eligible Classes Determining if You Are in an Eligible Class Obtaining Coverage for Dependents How and When to Enroll...6 Initial Enrollment in the Plan Late Enrollment Annual Enrollment Special Enrollment Periods When Your Coverage Begins...9 Your Effective Date of Coverage Your Dependent s Effective Date of Coverage Retired Employees How Your Medical Plan Works...10 Common Terms...10 About Your Aetna Choice POS II Medical Plan 10 Availability of Providers How Your Aetna Choice POS II Medical Plan Works...11 Accessing Providers Out-of-Country Care Understanding Precertification Services and Supplies Which Require Precertification Emergency and Urgent Care...16 In Case of a Medical Emergency Coverage for Emergency Medical Conditions In Case of an Urgent Condition Coverage for an Urgent Condition Non-Urgent Care Follow-Up Care After Treatment of an Emergency or Urgent Medical Condition Requirements For Coverage...19 What The Plan Covers...20 Aetna Choice POS II Medical Plan...20 Wellness...20 Routine Physical Exams Routine Cancer Screenings Family Planning Services Vision Care Services Limitations Hearing Exam Physician Services...26 Physician Visits Surgery Anesthetics Alternatives to Physician Office Visits Hospital Expenses Room and Board Other Hospital Services and Supplies Outpatient Hospital Expenses Coverage for Emergency Medical Conditions Coverage for Urgent Conditions Alternatives to Hospital Stays Outpatient Surgery and Physician Surgical Services Birthing Center Home Health Care Private Duty Nursing Skilled Nursing Facility Hospice Care Other Covered Health Care Expenses Acupuncture Ambulance Service Ground Ambulance Air or Water Ambulance Diagnostic and Preoperative Testing Diagnostic Complex Imaging Expenses Outpatient Diagnostic Lab Work and Radiological Services Outpatient Preoperative Testing Durable Medical and Surgical Equipment (DME) Experimental or Investigational Treatment Pregnancy Related Expenses Prosthetic Devices Autism Spectrum Disorder Short-Term Rehabilitation Therapy Services Cardiac and Pulmonary Rehabilitation Benefits Outpatient Cognitive Therapy, Physical Therapy, Occupational Therapy and Speech Therapy Rehabilitation Benefits Reconstructive or Cosmetic Surgery and Supplies Reconstructive Breast Surgery Specialized Care Chemotherapy Radiation Therapy Benefits Outpatient Infusion Therapy Benefits Enteral Formulas Treatment of Infertility Basic Infertility Expenses Advanced Reproductive Technology (ART) Benefits Exclusions and Limitations Spinal Manipulation Treatment... 42

30 Transgender Reassignment Surgery...42 Transplant Services...43 Network of Transplant Specialist Facilities Obesity Treatment...45 Treatment of Mental Disorders and Substance Abuse...46 Treatment of Mental Disorders Treatment of Substance Abuse Oral and Maxillofacial Treatment (Mouth, Jaws and Teeth)...48 Medical Plan Exclusions...50 When Coverage Ends...58 When Coverage Ends For Employees When Coverage Ends for Dependents Continuation of Coverage...60 Continuing Health Care Benefits Handicapped Dependent Children COBRA Continuation of Coverage...61 Continuing Coverage through COBRA Who Qualifies for COBRA Disability May Increase Maximum Continuation to 29 Months Determining Your Contributions For Continuation Coverage When You Acquire a Dependent During a Continuation Period When Your COBRA Continuation Coverage Ends Coordination of Benefits - What Happens When There is More Than One Health Plan...64 Other Plans Not Including Medicare...64 When You Have Medicare Coverage Effect of Medicare General Provisions Type of Coverage Physical Examinations Legal Action Confidentiality Additional Provisions Assignments Misstatements Incontestability Subrogation and Right of Reimbursement Worker s Compensation Recovery of Overpayments Health Coverage Reporting of Claims Payment of Benefits Records of Expenses Contacting Aetna Effect of Benefits Under Other Plans Effect of An Health Maintenance Organization Plan (HMO Plan) On Coverage Effect of Prior Coverage - Transferred Business 73 Discount Programs Discount Arrangements Incentives Claims, Appeals and External Review 73 Glossary * Defines the Terms Shown in Bold Type in the Text of This Document.

31 Preface Aetna Life Insurance Company (referred to as Aetna) is pleased to provide you with this Booklet. Read this Booklet carefully. The plan described in this Booklet is a benefit plan of the Employer. These benefits are not insured with Aetna or any of its affiliates, but will be paid from the Employer's funds. Aetna and its HMO affiliates will provide certain administrative services under the plan as outlined in the Administrative Services Agreement between Aetna and the Customer. This Booklet is part of the Contract between Aetna and the Customer. The Contract determines the terms and conditions of coverage. Aetna agrees with the Customer to provide coverage in accordance with the conditions, rights, and privileges as set forth in this Booklet. The Customer selects the products and benefit levels under the plan. A person covered under this plan and their covered dependents are subject to all the conditions and provisions of the Contract. The Booklet describes the rights and obligations of you and Aetna, what the plan covers and how benefits are paid for that coverage. It is your responsibility to understand the terms and conditions in this Booklet. Your Booklet includes the Schedule of Benefits and any amendments or riders. If you become covered, this Booklet replaces and supersedes all Booklets describing similar coverage that Aetna previously issued to you. Customer: Cornell University Contract Number: Contract Effective Date: January 1, 2014 Issue Date: July 1, 2014 Booklet Number: 8 2

32 Important Information Regarding Availability of Coverage No services are covered under this Booklet in the absence of payment of current fees. Coverage for You and Your Dependents Health Expense Coverage Benefits are payable for covered health care expenses that are incurred by you or your covered dependents while coverage is in effect. An expense is incurred on the day you receive a health care service or supply. This plan provides coverage for the following: Medical Plan Coverage under this plan is non-occupational. Only non-occupational injuries and non-occupational illnesses are covered. Conditions that are related to pregnancy may be covered under this plan. Refer to the What the Plan Covers section of the Booklet for more information about your coverage. Treatment Outcomes of Covered Services Aetna is not a provider of health care services and therefore is not responsible for and does not guarantee any results or outcomes of the covered health care services and supplies you receive. Providers of health care services, including, hospitals, institutions, facilities or agencies are independent contractors and are neither agents nor employees of Aetna or its affiliates. 3