Aetna Life Insurance Company Marsh & McLennan Aetna Choice POS II Plan ASC

Transcription

1 Plan Features Preferred Benefits Non-Preferred Benefits Plan Deductible Once Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the calendar year. $400 Individual $1000 Family $800 Individual $2000 Family AC-1 Deductible Carryover None None Coinsurance 80% 60% Coinsurance Limit (includes deductible) Once Family Coinsurance Limit is met, all family members will be considered as having met their coinsurance for the remainder of the calendar year. Lifetime Maximum* (excludes pharmacy) *Maximums are a combined limit for preferred and non-preferred services. $2,500 Individual $6,250 Family Unlimited $5,000 Individual $12,500 Family unlimited Physician Services (except Mental Health/Alcohol/Drug) Office Visits to PCP (Internist, General Physician, Family Practitioner or Pediatrician) 80% after deductible 60% after deductible Specialists (office visits) 80% after deductible 60% after deductible Routine Physicals/Immunizations Children: 7 exams in first 12 months of life, 3 exams in the 13th 24th months of life, 3 exams in the 25 th - 36 th months of life, 1 exam per calendar year thereafter up to age exam per calendar year thereafter age 18 and older (employee/dependents). Includes coverage for immunizations. Routine Gynecological Care Exam Coverage is limited to 1 routine Ob/Gyn exam per year, including charges for 1 pap smear and related lab fees. 100% no deductible 60% after deductible 100% no deductible 60% after deductible

2 AC-2 Plan Features Preferred Benefits Non-Preferred Benefits Routine Mammography One baseline ages One mammogram per calendar year for covered females age 40 and above. 100% no deductible 60% after deductible Routine Annual Digital Rectal Exam (DRE) and Prostate Antigen Test (PSA) for covered males age 40 and over 100% no deductible 60% after deductible Outpatient Surgery 80% after deductible 60% after deductible Physician hospital services 80% after deductible 60% after deductible Allergy Testing 80% after deductible 60% after deductible Allergy serum, allergy injections 80% after deductible 60% after deductible and injectable drugs Diagnostic X-ray & Laboratory 80% after deductible 60% after deductible Immunizations for business travel Not covered Not covered Physician Hospital Services 80% after deductible 60% after deductible Inpatient coverage 80% after deductible 60% after deductible Outpatient coverage 80% after deductible 60% after deductible Second Surgical Opinions Cover physician's exam and necessary x-ray, lab or other diagnostic procedures for a second opinion on the need or advisability of surgery (including oral surgery) that is: Recommended by the physician who will perform the surgery; Non-emergency in nature (the procedure can be postponed without undue risk to the patient).

3 AC-3 Plan Features Preferred Benefits Non-Preferred Benefits Midwife Nurse midwife who is in practice with a network group. Nurse midwife that can practice on their own, and who is not in practice with a network physician group. Multiple Surgical Procedures Primary procedure - allow 100% of the negotiated or reasonable and customary fee Secondary procedure - allow 50% of the negotiated or reasonable and customary fee. Tertiary and additional procedures allow 25% of the negotiated or reasonable and customary fee for each additional procedure Bilateral and separate operative areas allow 100% of the negotiated or reasonable and customary fee for the primary procedure and 50% of the secondary procedure and 25% of the negotiated or reasonable and customary fee for tertiary/additional procedures. Incidental surgeries are not reimbursed if billed separately (procedure that is performed at the same time as a primary procedure, which requires little additional physician resources and/or is clinically an integral part of the performance of the primary procedure). Emergency Room 80% after deductible 80% after deductible Non-emergency use of the Emergency Room Not covered Not covered Urgent Care Provider 80% after deductible 60% after deductible Non-Urgent Use Of Urgent Care Provider Not Covered Not Covered

4 AC-4 Plan Features Preferred Benefits Non-Preferred Benefits Convalescent Facility* *Maximums are a combined limit for preferred and non-preferred services. 80% after deductible up to 120 days per calendar year * 60% after deductible up to 120 days per calendar year * Home Health Care* (Excludes private duty nursing care - separate private duty nursing benefit available) *Maximums are a combined limit for preferred and non-preferred services. **Each visiting nurse care or private duty nursing care shift of 4 hours or less counts as one home health visit. Each such shift of over 4 hours and up to 8 hours counts as two home health care visits. Hospice Care - Inpatient Coverage Outpatient Coverage Short-Term Rehabilitation - Physical therapy Occupational therapy Speech therapy-(covered as required for treatment of a speech impediment or speech dysfunction that results from injury, stroke or a congenital anomaly.) (Excludes spinal manipulation under Short-Term Rehabilitation benefit.) *Note: Maximums are a combined limit for preferred and non-preferred services. Spinal Manipulation (If coverage is not included under Short Term Rehabilitation benefit.) *Note: Maximums are a combined limit for preferred and non-preferred services. 80% after deductible up to 120 visits per calendar year* 80% after deductible. No limit. 80% after deductible. No limit. 80% after deductible up to 60 visits per calendar year* 80% after deductible up to 20 visits per calendar year.* 60% after deductible up to 120 visits per calendar year* 60% after deductible. No limit. 60% after deductible. No limit. 60% after deductible up to 60 visits per calendar year* 60% after deductible up to 20 visits per calendar year.*

5 AC-5 Plan Features Preferred Benefits Non-Preferred Benefits Ambulance 80% after deductible 80% after deductible Durable Medical Equipment (excludes orthotics) Inhaler spacers (2 spacers per year) Medical DME Diabetic devices (blood glucose monitors) 1 monitor per year covered through patient management. 80% after deductible 60% after deductible Hearing Care (Due to illness or injury) (Hearing Aids) 80% after deductible Not Covered 60% after deductible Not Covered Mouth, Jaws and Teeth (Covers oral surgery procedures that is medical in nature) Maternity (Coverage includes voluntary sterilization and voluntary abortion.) Contraceptive Devices Injectable contraceptive devices whether or not medically necessary when provided by physician as part of an office visit. Basic Infertility Services Diagnosis and treatment of the underlying medical condition For ART INSEM and OVUL INDUCT limited to 6 separate attempts per lifetime and ADVANCED REPRODUCTIVE TECH limited to 3 separate attempts per lifetime. No dollar limit. Injectable drugs covered on RX-Drug plan no limit. 80% after deductible 60% after deductible 80% after deductible 60% after deductible 80% after deductible 60% after deductible 80% after deductible 60% after deductible

6 AC-6 Plan Features Preferred Benefits Non-Preferred Benefits Mental Health *Maximums are a combined limit for preferred and non-preferred services. Inpatient Coverage 80% after deductible unlimited days per calendar year 60% after deductible unlimited days per calendar Outpatient Coverage Alcohol and Drug Abuse Services *Maximums are a combined limit for preferred and non-preferred services. Inpatient Coverage Outpatient Coverage Inpatient Procedures, Treatments and Services Inpatient precertification and concurrent review Penalty to employee for failure to precertify Applies to inpatient hospital; treatment facility; convalescent facility; home health care and hospice care. 80% after deductible unlimited visits per calendar 80% after deductible unlimited days per calendar year 80% after deductible unlimited visits per calendar Provider initiated None 60% after deductible unlimited visits per calendar year 60% after deductible unlimited days per calendar 60% after deductible unlimited visits per calendar year Member initiated $400 penalty. Applies per occurrence.

7 AC-7 Outpatient procedures and services Ambulatory Procedure Review Provider initiated Member initiated Penalty to employee for failure to precertify Outpatient Pre-certification applies to: Allergy Immunotherapy, Bunionectomy, Carpal Tunnel Surgery, Colonoscopy, Coronary Angiography, CT Scan spine, Dilation & Curettage (D&C), Hemorrhoidectomy, Knee Arthroscopy, Laparoscopy (Pelvic), MRI knee, MRI spine, Septoplasty, Tympanostomy Tube, UGI Endoscopy None $400 penalty. Applies per occurrence. Claim Submission Provider initiated Member initiated External Review Program Enables members to request an external review of certain coverage decisions by an independent physician reviewer after the plan s applicable appeals process has been exhausted. Included Eligible members may request an external review when: The Plan s applicable review process has been exhausted & resulted in a coverage denial; Coverage is being denied either because the proposed or rendered service or treatment is not medically necessary, or because it is considered experimental or investigational; and The cost of the service or treatment at issue for which the member is financially responsible exceeds $500. Many states have mandated external review processes that differ considerably from Aetna s process. Certain states mandate external review of other benefit or service issues, or require a filing fee. In addition, certain states mandate the use of their own external reviewers. These state mandates may not apply to selffunded plans. For further details regarding external review program for a specific state, a member can contact Member Services at the toll-free number on their ID card or contact the state insurance or health department for additional information regarding state mandated external review processes.

8 AC-8 National Advantage Program The National Advantage Program (NAP) offers access to contracted rates for many hospital and physician claims that would otherwise be paid at billed charges under indemnity plans, the outof-network portion of managed care plans, or for emergency/medically necessary services not provided within the network. The NAP network consists of many of Aetna s directlycontracted hospitals, ancillary providers, and physicians as well as hospitals, ancillary providers, and physicians accessed through vendor arrangements. Value-Added Programs Members have access to the following special programs: Included Included Alternative Health Care Programs are made up of three distinct segments. Natural Alternatives - offers special rates on alternative therapies, including visits to acupuncturists, chiropractors, massage therapist and nutritional counselors. 5 Vitamin Advantage - a savings program for over-thecounters vitamins as well as nutritional supplements Natural Products a savings program for many healthrelated products (via Global Fit). Fitness program for savings on health club memberships and home exercise equipment. 5 Availability varies by service area.

9 AC-9 National Medical Excellence Program (NME) A program to help eligible members access appropriate, covered treatment for solid organ and tissue transplants using Aetna s Institutes of Excellence network, and may also include travel expenses for the member and a companion. Coordinates specialized treatment needed by members with certain rare or complicated conditions and assist members who are admitted to a hospital for emergency medical care when they are traveling temporarily outside of the United States Transplants National Transplant Program coordinates care and provides access to covered treatment through the Institutes of Excellence network. If procedure is performed through an Institutes of Excellence network, benefits would be paid at the preferred level. If procedure is not performed through Institutes of Excellence network, benefits would be paid at the non-preferred level. Informed Health Line Included Included Included A 24-hour toll-free telephone number than links members to a team of experienced registered nurses who can provide information on a variety of health issues. 1 Informed HealthLine now also includes an audio health library, giving members a new way to access creditable health information from any touch-tone phone, 24 hours a day; available in English and Spanish 1 Informed Health Line nurses can not diagnose, prescribe or give medical advice. Specific questions should be addressed by a members doctor.

10 AC-10 Eligibility An employee classified on payroll as a U.S. salaried employee of MMC or any subsidiary or affiliate of MMC (other than Putnam Investments, Inc.). Individuals classified on payroll as hourly employees or who are compensated as independent contractors are not eligible to participate. Dependents Eligibility Spouse, children from birth to the end of the month in which the child attains age 26. Includes approved incapacitated children. Student Verification Newborns Domestic Partners For 2005 student verification will begin in September with the first claim submitted. Must be reported within 31 days Approved opposite gender or same gender Termination Rule Private Room Limit Reasonable & Customary Date of termination Semi-Private room rate 85% (updated twice a year - July and January) Claim Fiduciary Employee Actively-At- Work/Dependent Non Confinement Cobra Continuation Contribution Rule HIPAA Certificates Conversion Continuation Extension of Benefits Aetna Applies. Must be fulfilling job responsibilities at a Companyapproved location on the day coverage is supposed to begin (e.g., not out ill or on a leave of absence). Standard continuation applies Yes MMC produces Not applicable Active employees-12 months. Pre 65 retirees-lifetime or remarriage. Once retired can elect retiree medical or waive out of plan. None

11 Medicare Government Exclusion - Medicare eligible benefits are subtracted from Covered Medical Expenses before secondary Aetna benefits are calculated. AC-11 Coordination with Other Benefits Subrogation Order of Benefit Determination The plan that covers the employee or the employee's spouse as the employee pays its benefits before the plan that covers employee or employee's spouse as a family member. Third party liability claims with recovery potential will be forwarded to the designated subrogation vendor for pursuit. Standard rules apply. (The benefit plan of the parent whose birthday falls earlier in the calendar year pays first. If employee and spouse have the same birthday, the plan that covered employee or employee's spouse longer pays first. If the other plan does not have the parent birthday rule, the other plan's coordination of benefits rule applies.) Aetna contractual definitions will apply to treatment received in as well as out of network. Deductible Deductible is an out-of-pocket expense applicable to preferred and /or non-preferred benefits. Covered preferred and/or non-preferred expenses are reduced by the amount of the deductible at the time of claim adjudication by the claim processor. All out-of-pocket expenses applicable to preferred and/or nonpreferred benefits (except those resulting from application of a coinsurance percentage, e.g., 80%, 70%, 50% etc.) are referred to as deductibles. The preferred and/or non-preferred calendar year deductible is individual and family, with family limits equal to none, 2x or 3x the individual deductible. The family deductible limit does not apply to mental/nervous and alcoholism and drug expenses. Deductible applicable to preferred and non-preferred benefits will apply independently (i.e., no cross application between calendar year and per confinement deductibles). There is no deductible carryover provision. Coinsurance Limits Coinsurance limits are the maximum amount of out-of-pocket expenses (other than copays and deductibles) that an employee/family will have to pay in a calendar year. Expenses are reimbursed at 100% once these limits are met. Coinsurance limits where included apply independently (i.e., no cross application of preferred and non-preferred expenses). Coinsurance limits apply on a calendar year basis only. Coinsurance limits are individual and family, with family limits equal to none, 2x or 3x the individual limit.

12 AC-12 Expenses applicable to coinsurance limit - Only those out-of-pocket expenses resulting from the application of a coinsurance percentage (except deductibles, copays and any penalty amounts) may be used to satisfy the coinsurance limit. Service Area Employees living outside of the service area may be covered under a separate plan of benefits.