Aetna Avenue Your Destination for Small Business Solutions

Transcription

1 Aetna Avenue Your Destination for Small Business Solutions Illinois PLAN GUIDE Plans effective October 1, IL (10/10)

2 I l l i n o i s p l a n G U I D E Health care is a journey A e t n a Av e n u e i s t h e way I n t h i s g u i d e : 2 Small business commitment 3 Benefits for every stage of life 4 Medical overview 7 Managing health care expenses 8 Medical plan options 18 Dental overview 20 Dental plan options 28 Life & disability overview 30 Life plan options 30 Disability plan options 31 Life & disability plan options 32 Underwriting guidelines 37 Product specifications 44 Limitations and exclusions As a small business owner, providing value to your customers and growing your business are your top priorities. Yet, today health care is a business issue for every entrepreneur. Small businesses need insurance benefits plans that fit their workplace. Aetna Avenue provides employers with a choice of insurance benefits solutions. We know that choice, ease and reputation are as valuable to employers as they are to employees. Aetna offers a variety of plans for small business from medical plans, to dental, life and disability plans. Health benefits and health insurance, dental benefits/dental insurance, life insurance and disability insurance plans/policies are offered, underwritten or administered by Aetna Health of Illinois Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna).

3 C H O I C E For business owners and employees At Aetna, we provide employers a choice of insurance benefits plans. Within these benefits programs, employers can choose specific plan designs that fit business and employee needs. And, employees have access to a wide network of doctors and other providers ensuring that they have a choice in how they receive their health care. Medical plans supporting members on their health care journey Consumer-directed health plans (CDHP) HSA-Compatible plans Traditional plans Community plans Dental, life and disability plans providing valuable protection DMO * PPO PPO Max Freedom of Choice Plan Design Preventive Basic term life insurance Disability plans Packaged life and disability plans E a s e Allowing you to focus on your business Employers want to focus on their customers and growing their business not the insurance benefits program. Aetna makes sure that our plan designs are easy to set-up, administer, use and provide support to ensure your success. Administration making it work for your business Aetna s plan designs automatically process health claim reimbursements, provide direct deposit and a password-protected website to keep track of accounts and are supported by knowledgeable service representatives. Our representatives are available to answer your questions and work with you when you need them. Ready on day-one making it work for your employees Once employees are members of the Aetna health benefits and health insurance plans, they ll have access to our various tools and resources to help them use the plans effectively from the start. Aetna Navigator our online resource for employers, members and providers DocFind to locate doctors in the neighborhood Track medical claims online Discount programs for eye, dental and other health care** Personal Health Record providing a complete picture of health Simple Steps to a Healthier Life, an online health and wellness program Temporary ID cards available for members to print as needed Knowledgeable customer service a valuable resource for members Ready to answer questions Online access 24 hours a day, 7 days a week access for answers to your questions Aetna Health Connections SM disease management Our newly redesigned capabilities offer support for over 30 conditions as well as integrated care for members with multiple conditions. The program includes cutting-edge technology that helps improve patient safety, doctor communication and more. R e p u tat i o n In business it s everything Your reputation is important to your business. At Aetna, our reputation is just as important. With 150 years of experience, we value our name, products and services and focus on delivering the right solution for your small business our reputation depends upon it. Our account executives, underwriters and customer service representatives are committed to providing your small business the valuable service it deserves. We want you to know that Aetna delivers. * In IL, DMO plans provide limited out-of-network benefits. However, in order to receive maximum benefits, members must select and have care coordinated by a participating primary care dentist. Illinois DMO is not an HMO. **These discount programs may not be available to Illinois residents. 1 M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G

4 I l l i n o i s p l a n G U I D E A e t n a Av e n u e s c o m m i t m e n t t o s m a l l b u s i n e s s e m p l oy e r s We know that small business owners insurance benefits needs are often different than a larger employer. Aetna Avenue focuses on employers with 2-50 employees and our insurance benefits programs are designed to work for this size group. We ll work with you to determine the right plans for your business and assist you through implementation. A e t n a s m a r k e t m a p Guiding your small business health care journey Aetna s market map is a resource for brokers and employers to help determine the right insurance benefits plan for their business. The market map asks specific questions related to the business and employee need in order to narrow the field of plan design choices. Basic benefits for your employees These plans fit HSA-Compatible Plans Limiting the expense to your business Allowing employees to buy-up and share more of the cost You might be a Basic buyer Employee responsibility These plans fit D o yo u va l u e Consumerism s ability to make a difference Tools and resources to support consumerism Innovative plan design You might be a Value seeker HSA-Compatible Plans Consumer-directed health plans Community Plans Traditional benefits plans Limiting the financial impact on employees You might be a Traditionalist These plans fit Traditional plans 2

5 Y o u n g S i n g l e s Consumer-directed health plans HSA-Compatible plans Y o u n g Fa m i l i e s Traditional plans Community plans E s ta b l i s h e d Fa m i ly Consumer-directed health plans HSA-Compatible plans Community plans E m p t y N e s t e r s Consumer-directed health plans HSA-Compatible plans H e a lt h i n s u r a n c e b e n e f i t s f o r e v e r y s tag e o f l i f e Yo u n g s i n g l e s Includes singles and couples without children Ready to conquer the world? Thinking big thoughts? Well, one of those thoughts should be about health coverage. Since they re probably on a budget, they might want an affordable policy with lower monthly payments and modest out-ofpocket costs that also provides for quality preventive care, prescription drug coverage and financial protection to help safeguard their assets. Yo u n g fa m i l i e s Includes married couples and single parents with young children and teens Children tend to get sick more than adults which means employees and their pediatricians get to know each other quite well. It also means they re probably looking for health coverage with lower fees for office visits, lower monthly payments and caps on their out-of-pocket expenses. And, of course, they can benefit from quality preventive care for the entire family. Established families Includes married couples and single parents with teens and college-aged children As the children get older, the entire family s needs change. Time management is important for active parents and children. Teenagers still need checkups and care for injuries and illness, while parents need to start thinking about their own needs, like plan designs that cover preventive care and screenings and promote a healthy lifestyle. And college brings financial concerns to the forefront, as well as the need for a national network. E m p t y n e s t e r s Includes men and women age 55 and over with no children at home The kids are leaving home. It s a wistful time, but also an exciting one. What are the plans? Travel? Leisure? Reassessing health coverage needs? These employees are probably looking for a policy that combines financial security with quality coverage for prescriptions, hospital inpatient/outpatient services and emergency care. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 3

6 I l l i n o i s p l a n G U I D E Aetna Open Access Managed Choice network:* Alexander Bond Boone Brown Calhoun Christian Clark Clay Clinton Cook DuPage Edgar Edwards Fayette Ford Franklin Gallatin Greene Grundy Hamilton Hardin Iroquois Jackson Jasper Jersey Johnson Kane Kankakee Kendall Lake Lawrence Logan Macoupin Madison Mason Massac McHenry Menard Monroe Montgomery Perry Pope Pulaski Randolph Sangamon Schuyler Scott St. Clair Union Wabash Washington Wayne White Will Williamson Winnebago PPO plan network:* Alexander Bond Boone Brown Bureau Calhoun Champaign Christian Clark Clay Clinton Coles Cook Crawford DeKalb Douglas DuPage Edgar Edwards Effingham Fayette Ford Franklin Fulton Gallatin Greene Grundy Hamilton Hardin Henry Iroquois Jackson Jasper Jefferson Jersey Jo Daviess Johnson Kane Kankakee Kendall Knox Lake LaSalle Lawrence Lee Livingston Logan Macon Macoupin Madison Marion Marshall Mason Massac McDonough McHenry McLean Menard Monroe Montgomery Morgan Ogle Peoria Perry Piatt Pope Pulaski Putnam Randolph Rock Island Saline Sangamon Schuyler Scott Stark St. Clair Stephenson Tazewell Union Vermilion Wabash Warren Washington Wayne White Whiteside Will Williamson Winnebago Woodford Aetna Avenue M e d i c a l Ov e r v i e w M U LT I - O P T I O N O F F E R I N G S Greater employee choice Employers can offer any 3 of the 17 available plan designs. Flexibility and affordability Employers can create a customized benefits package from any of our plan types and plan designs. Aetna offers a variety of plans at different price points. Employers may designate a level of contribution that meets their budget. Target audience Plan choices Minimum participation Multi-Option Offerings Every small business with 5+ enrolled employees Up to 3 of the 17 available plans 70% of eligible employees required Employer contribution 50% of the employee rate or $120 Total freedom Aetna offers 17 plan choices that range in price and benefits to help meet each individual employee s needs, whether they are lower premiums or lower out-of-pocket costs at the time services are received. Easy administration Setting up this program is simple: 1. The employer chooses up to 3 plans to offer on the Employer Application 2. The employer chooses how much to contribute 3. Each employee chooses the plan that s right for him or her HMO network:* Cook DuPage Kane Kankakee Lake McHenry Will *Network subject to change. *Accessed from Aetna s Enterprise Provider Database on 1/1/10. 4

7 T h e A e t n a I l l i n o i s C o m m u n i t y P l a n S M The Aetna Illinois Community Plan is helping Chicagoland small and midsize businesses get access to health services that fit their needs and their wallets. It allows members access to an affordable custom community network of health providers within reach and close to home. An accessible route to health insurance The Aetna Illinois Community Plan SM network includes physicians from most specialities. Also, because the network is based in the community, access is easier and costs are lower. Additional features of the plan include: Spanish-speaking providers are available. Coverage can be extended to spouses and children. Includes prescription drugs. Medical attention for whatever path you take* Over 40 hospitals Over 2400 primary care physicians Over 740 OB/GYNs Over 5600 specialists Over 2000 behavioral health providers An easy-to-navigate insurance plan Aetna s plans are easy to set up, administer and use. Once enrolled, you will not only have access to your health insurance benefits, but online resources and information to help you and your employees make more informed healthrelated decisions. More benefits, mile after mile Aetna s business clients can tap into corporate buying power through Aetna s Resource Connection which features discounted goods and services. While not insurance, these discounts** can help you save on office supplies, HR support, Payroll, Technology assistance and more. Members are encouraged to select a Primary Care Physician (PCP) that will coordinate their health care needs for covered services or benefits for either of the following access options: Community Network providers more economical Generally lower out-of-pocket costs when accessing care from physicians in the Community Network. Members have access to a custom community network within reach and close to home. No claim forms for members to submit. No referrals required. *Accessed from Aetna s Enterprise Provider Database on 1/1/10. **Discount programs provide access to discounted prices and are NOT insured benefits. The member is responsible for the full cost of the discounted services. Managed Choice Network providers costs may be higher ( toll required ) Generally higher out-of-pocket costs when accessing care from physicians in the Managed Choice Network. No claim forms for members to submit. No referrals required. For a complete list of providers, please visit M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 5

8 I l l i n o i s p l a n G U I D E Administrative fees FEE DESCRIPTION HSA FEE Initial Set-Up $0 Monthly Fees $0 POP* Initial Set-Up** $150 Renewal $75 HRA and FSA*** Initial Set-Up* 2-25 Employees $ Employees $ Employees $550 Renewal Fee 50% of the initial set-up fee Monthly Fees Additional Set-Up Fee for stacked plans (those electing an Aetna HRA and FSA simultaneously) Participation Fee for stacked participants $5.00 per participant $150 $9.75 per participant Minimum Fees 0-25 Employees $10 per month minimum Employees $5- per month minimum TRA Annual Fee $350 Transit Monthly Fees Parking Monthly Fees COBRA Annual Fee Employees Monthly Fee $4.25 per participant $3.15 per participant $50 $0.85 per employee Health Reimbursement Arrangement (HRA) The Aetna HealthFund HRA combines the protection of a deductible-based health plan with a health fund that pays for eligible health care services. The member cannot contribute to the HRA, and employers have control over HRA plan designs and fund rollover. The fund is available to an employee for qualified expenses on the plan s effective date. The HRA and the HSA provide members with financial support for higher outof-pocket health care expenses. Aetna s consumer-directed health products and services give members the information and resources they need to help make informed health care decisions for themselves and their families while helping lower employers costs. Underlying Plan Policy Aetna premium rates assume no underlying plans are present and deductible is funded at no more than 50% annually. An underlying or wrap around plan is a plan that either partially or completely subsidizes any member cost sharing outside of a federally-qualified Health Reimbursement Account (HRA) or Health Savings Account (HSA). Member cost sharing includes but is not limited to copays, deductibles and/or member coinsurance balances. (Employee funded Flexible Spending Accounts are not considered underlying plans). Small employers must attest that no such underlying plans are present and that they are not funding the deductible in excess of 50% annually whether through an HRA or HSA on the new business final rates and renewal plan sponsor signature pages. Section 125 Cafeteria Plans and Section 132 Transit Reimbursement Accounts Employees can reduce their taxable income, and employers can pay less in payroll taxes. There are three ways to save: Premium Only Plans (POP) Employees can pay for their portion of the group health insurance expenses on a pretax basis. First-year POP fees with the purchase of medical with 5-plus enrolled employees. Flexible Savings Account (FSA) FSAs give employees a chance to save for health expenses with pretax money. Health Care Spending Accounts allow employees to set aside pretax dollars to pay for outof-pocket expenses as defined by the IRS. Dependent Care Spending Accounts allow participants to use pretax dollars to pay child or elder care expenses. Transit Reimbursement Account (TRA) TRAs allow participants to use pretax dollars to pay transportation and parking expenses for the purpose of commuting to and from work. C O B R A a d m i n i s t r at i o n Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes that can assist employers with managing the complex billing and notification processes that are required for COBRA compliance, while also helping to save them time and money. *First year POP fees with the purchase of medical with 5-plus enrolled employees. ** Non-discrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle testing available at employer request for $75 fee. Non-discrimination testing only available for FSA and POP products. *** Aetna FSA pricing is inclusive for POP. Debit cards are available for FSA only. Contact Aetna for further information. For HRA, if the employer opts out of Streamline, the fee is increased $1.50 per participant. HRAs are currently not available to HMO members in Illinois. Aetna HealthFund HRAs are subject to employer-defined use and forfeiture rules, and are unfunded liabilities of your employer. Fund balances are not vested benefits. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information subject to change. Aetna reserves the right to change any of the above fees and to impose additional fees upon prior written notice. 6

9 A way t o m a n ag e h e a lt h a n d h e a lt h c a r e e x p e n s e s Health Savings Account (HSA)* The Aetna HealthFund HSA, when coupled with a HSA-compatible highdeductible health benefits and health insurance plan, is a tax-advantaged savings account. Once enrolled, account contributions can be made by the employee and/or employer. The HSA can be used to pay for qualified expenses tax free. H S A Ac c o u n t You own your HSA Contribute tax free You choose how and when to use your dollars Roll it over each year and let it grow Earns interest, tax free T o d ay Use for qualified expenses with tax-free dollars Yo u r H S A P l a n F u t u r e Plan for future and retiree health-related costs H i g h - d e d u c t i b l e h e a lt h p l a n Eligible in-network preventive care services will not be subject to the deductible You pay 100% until deductible is met, then only pay a share of the cost Meet out-of-pocket maximum, then plan pays 100% *HSAs are currently not available to HMO members in Illinois. **Discount programs provide access to discounted prices and are NOT insured benefits. The member is responsible for the full cost of the discounted services. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 7

10 I l l i n o i s p l a n G U I D E A e t n a S m a l l G r o u p T r a d i t i o n a l M e d i c a l P l a n s Aetna Plan Options $250 90/70 (10/10) + $500 90/70 (10/10) + Networks Available Aetna Managed Choice POS Open Access Aetna Managed Choice POS Open Access Aetna Open Choice PPO Member Benefits In-Network Out-of-Network 1 In-Network Out-of-Network 1 PCP Referrals Required No N/A No N/A Plan Coinsurance (applies to most services) 90% 70% 90% 70% Calendar Year Deductible 2 Calendar Year Coinsurance Maximum 3 (Excludes deductible, copayments, member coinsurance payments for DME, and copayments for prescription drugs) $250 per member $750 family $1,000 per member $3,000 family $500 per member $1,500 family $2,000 per member $6,000 family $500 per member $1,500 family $1,000 per member $3,000 family Lifetime Maximum Benefit Unlimited Unlimited Primary Physician Office Visit Specialist Office Visit Outpatient Lab $25 copay, deductible $45 copay, deductible $25 copay, deductible 70% $25 copay, deductible 70% $45 copay, deductible 70% $25 copay, deductible Outpatient X-Ray 90% 70% 90% 70% Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET Scans; precertification required) Well Baby/Child Exams/Immunizations & Adult Physical Exams/Immunizations/Routine GYN Exams/Routine Mammograms (Age/Frequency Schedules Apply) Routine Eye Exam (One exam per 24 months. In and out-of-network combined.) $1,000 per member $3,000 family $2,000 per member $6,000 family 70% 70% 70% 90% 70% 90% 70% $0 copay, deductible $0 copay, deductible 70% $0 copay, deductible 70% $0 copay, deductible Inpatient Hospital 90% 70% 90% 70% Outpatient Surgery 90% 70% 90% 70% Emergency Room (Copay if admitted) Urgent Care Outpatient Physical/Occupational Therapy and Chiropractic Services (40 visits per calendar year.) and Outpatient Speech Therapy (12 visits per calendar year.) (In and out-of-network combined.) Prescription Drugs (Includes insulin) Retail: per 30-day supply Mail Order: two times retail copay, day supply $50 copay, deductible $150 copay, deductible 70% $50 copay, deductible 70% 70% $150 copay, deductible 70% 90% 70% 90% 70% $10/$40/$65 70% after $10/$40/$65 $10/$40/$65 70% after $10/$40/$65 90-Day Rx Transition of Coverage Included Included (TOC) for Prior Certification 4 For footnotes, see page 17. 8

11 A e t n a S m a l l G r o u p T r a d i t i o n a l M e d i c a l P l a n s Aetna Plan Options $500 80/60 (10/10) + $1,000 80/60 (10/10) + Networks Available Aetna Managed Choice POS Open Access Aetna Managed Choice POS Open Access Aetna Open Choice PPO Member Benefits In-Network Out-of-Network 1 In-Network Out-of-Network 1 PCP Referrals Required No N/A No N/A Plan Coinsurance (applies to most services) 80% 60% 80% 60% Calendar Year Deductible 2 Calendar Year Coinsurance Maximum 3 (Excludes deductible, copayments, member coinsurance payments for DME, and copayments for prescription drugs) $500 per member $1,500 family $2,000 per member $6,000 family $1,000 per member $3,000 family $4,000 per member $12,000 family $1,000 per member $3,000 family $2,000 per member $6,000 family Lifetime Maximum Benefit Unlimited Unlimited Primary Physician Office Visit Specialist Office Visit Outpatient Lab $30 copay, deductible $50 copay, deductible $30 copay, deductible 60% $30 copay, deductible 60% $50 copay, deductible 60% $30 copay, deductible Outpatient X-Ray 80% 60% 80% 60% Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET Scans; precertification required) Well Baby/Child Exams/Immunizations & Adult Physical Exams/Immunizations /Routine GYN Exams/Routine Mammograms (Age/Frequency Schedules Apply) Routine Eye Exam (One exam per 24 months. In and out-of-network combined.) $2,000 per member $6,000 family $4,000 per member $12,000 family 60% 60% 60% 80% 60% 80% 60% $0 copay, deductible $0 copay, deductible 60% $0 copay, deductible 60% $0 copay, deductible Inpatient Hospital 80% 60% 80% 60% Outpatient Surgery 80% 60% 80% 60% Emergency Room (Copay if admitted) Urgent Care Outpatient Physical/Occupational Therapy and Chiropractic Services (40 visits per calendar year.) and Outpatient Speech Therapy (12 visits per calendar year.) (In and out-of-network combined.) Prescription Drugs (Includes insulin) Retail: per 30-day supply Mail Order: two times retail copay, day supply $50 copay, deductible $150 copay, deductible 60% $50 copay, deductible 60% 60% $150 copay, deductible 60% 80% 60% 80% 60% $10/$40/$65 70% after $10/$40/$65 $10/$40/$65 70% after $10/$40/$65 90-Day Rx Transition of Coverage Included Included (TOC) for Prior Certification 4 For footnotes, see page 17. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 9

12 I l l i n o i s p l a n G U I D E A e t n a S m a l l G r o u p T r a d i t i o n a l M e d i c a l P l a n s Aetna Plan Options $1,500 80/60 (10/10) + Networks Available Aetna Managed Choice POS Open Access Member Benefits In-Network Out-of-Network 1 PCP Referrals Required No N/A Plan Coinsurance (applies to most services) 80% 60% Calendar Year Deductible 2 Calendar Year Coinsurance Maximum 3 (Excludes deductible, copayments, member coinsurance payments for DME, and copayments for prescription drugs) Lifetime Maximum Benefit Primary Physician Office Visit Specialist Office Visit Outpatient Lab $1,500 per member $4,500 family $2,000 per member $6,000 family $30 copay, deductible $50 copay, deductible $30 copay, deductible Unlimited Outpatient X-Ray 80% 60% Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET Scans; precertification required) Well Baby/Child Exams/Immunizations & Adult Physical Exams/Immunizations /Routine GYN Exams/Routine Mammograms (Age/Frequency Schedules Apply) Routine Eye Exam (One exam per 24 months. In and out-of-network combined.) $3,000 per member $9,000 family $4,000 per member $12,000 family 60% 60% 60% 80% 60% $0 copay, deductible 60% $0 copay, deductible 60% Inpatient Hospital 80% 60% Outpatient Surgery 80% 60% Emergency Room (Copay if admitted) Urgent Care Outpatient Physical/Occupational Therapy and Chiropractic Services (40 visits per calendar year.) and Outpatient Speech Therapy (12 visits per calendar year.) (In and out-of-network combined.) Prescription Drugs (Includes insulin) Retail: per 30-day supply Mail Order: two times retail copay, day supply 90-Day Rx Transition of Coverage (TOC) for Prior Certification 4 $50 copay, deductible $150 copay, deductible 60% 80% 60% $10/$40/$65 70% after $10/$40/$65 Included For footnotes, see page

13 A e t n a S m a l l G r o u p C o n s u m e r D i r e c t e d M e d i c a l P l a n s Aetna Plan Options CDHP $2,500 90/70 (10/10) + CDHP $3,000 80/60 (10/10) + Networks Available Aetna Managed Choice POS Open Access Aetna Open Choice PPO Aetna Managed Choice POS Open Access Member Benefits In-Network Out-of-Network 1 In-Network Out-of-Network 1 PCP Referrals Required No N/A No N/A Plan Coinsurance (applies to most services) 90% 70% 80% 60% Calendar Year Deductible 2 Calendar Year Coinsurance Maximum 3 (Excludes deductible, copayments, member coinsurance payments for DME, and copayments for prescription drugs) $2,500 per member $7,500 family $1,000 per member $3,000 family $5,000 per member $15,000 family $2,000 per member $6,000 family $3,000 per member $9,000 family $2,000 per member $6,000 family Lifetime Maximum Benefit Unlimited Unlimited Primary Physician Office Visit Specialist Office Visit Outpatient Lab $30 copay, deductible $50 copay, deductible $30 copay, deductible 70% $30 copay, deductible 70% $60 copay, deductible 70% $30 copay, deductible Outpatient X-Ray 90% 70% 80% 60% Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET Scans; precertification required) Well Baby/Child Exams/Immunizations & Adult Physical Exams/Immunizations /Routine GYN Exams/Routine Mammograms (Age/Frequency Schedules Apply) Routine Mammograms (Age/Frequency Schedules Apply) $6,000 per member $18,000 family $4,000 per member $12,000 family 60% 60% 60% 90% 70% 80% 60% $0 copay, deductible 70% $0 copay, deductible 60% $0 copay, deductible 70% $0 copay, deductible 60% Inpatient Hospital 90% 70% 80% 60% Outpatient Surgery 90% 70% 80% 60% Emergency Room (Copay if admitted) Urgent Care Outpatient Physical/Occupational Therapy and Chiropractic Services (40 visits per calendar year.) and Outpatient Speech Therapy (12 visits per calendar year.) (In and out-of-network combined.) Prescription Drugs Retail: per 30-day supply Mail Order: two times retail copay, day supply, includes insulin $50 copay, deductible $150 copay, deductible 70% $50 copay, deductible $150 copay, deductible 60% 90% 70% 80% 60% $10/$40/$65 70% after $10/$40/$65 $10/$40/$65 70% after $10/$40/$65 90-Day Rx Transition of Coverage Included Included (TOC) for Prior Certification 4 For footnotes, see page 17. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 11

14 I l l i n o i s p l a n G U I D E A e t n a S m a l l G r o u p H S A C o m pat i b l e M e d i c a l P l a n s Aetna Plan Options HSA Compatible $2,500 (EMB) 90/70 HSA Compatible $3,500 (EMB) 90/70 (10/10) + (10/10) + Networks Available Aetna Managed Choice POS Open Access Aetna Open Choice PPO Aetna Managed Choice POS Open Access Member Benefits In-Network Out-of-Network 1 In-Network Out-of-Network 1 PCP Referrals Required No N/A No N/A Plan Coinsurance (applies to most services) 90% 70% 90% 70% Calendar Year Deductible 2 Calendar Year Out-of-Pocket Maximum 3 (Includes deductible and copayments including those for prescription drugs) $2,500 per member $5,000 family (Embedded) $5,000 per member $10,000 family (Embedded) $5,000 per member $10,000 family (Embedded) $10,000 per member $20,000 family (Embedded) $3,500 per member $7,000 family (Embedded) $5,950 per member $11,900 family (Embedded) Lifetime Maximum Benefit Unlimited Unlimited Primary Physician Office Visit $30 copay 70% $30 copay 70% Specialist Office Visit $30 copay 70% $30 copay 70% Outpatient Lab 90% 70% 90% 70% Outpatient X-Ray 90% 70% 90% 70% Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET Scans; precertification required) Well Baby/Child Exams/Immunizations & Adult Physical Exams/Immunizations /Routine GYN Exams/Routine Mammograms (Age/Frequency Schedules Apply) Routine Mammograms (Age/Frequency Schedules Apply) 90% 70% 90% 70% $0 copay, deductible $0 copay, deductible 70% $0 copay, deductible 70% $0 copay, deductible Inpatient Hospital 90% 70% 90% 70% Outpatient Surgery 90% 70% 90% 70% Emergency Room (Copay if admitted) 90% 90% Urgent Care $50 copay 70% $50 copay 70% Outpatient Physical/Occupational Therapy and Chiropractic Services (40 visits per calendar year.) and Outpatient Speech Therapy (12 visits per calendar year.) (In and out-of-network combined.) Prescription Drugs Retail: per 30-day supply Mail Order: two times retail copay, day supply, includes insulin $7,000 per member $14,000 family (Embedded) $12,000 per member $24,000 family (Embedded) 70% 70% 90% 70% 90% 70% $10/$40/$65 after integrated deductible 70% after $10/$40/$65 after integrated deductible $10/$40/$65 after integrated deductible 90-Day Rx Transition of Coverage Included Included (TOC) for Prior Certification 4 70% after $10/$40/$65 after integrated deductible For footnotes, see page

15 A e t n a S m a l l G r o u p I n d e m n i t y M e d i c a l P l a n Aetna Plan Options Indemnity $ (10/10) + Networks Available Member Benefits PCP Referrals Required N/A Plan Coinsurance (applies to most services) 80% Calendar Year Deductible 2 $500 per member $1,500 family Calendar Year Coinsurance Maximum 3 (Excludes deductible, copayments, member coinsurance payments for DME, and copayments for prescription drugs) Lifetime Maximum Benefit For footnotes, see page 17. N/A $2,000 per member $6,000 family Unlimited Primary Physician Office Visit 80% Specialist Office Visit 80% Outpatient Lab 80% Outpatient X-Ray 80% Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET Scans; precertification required) Well Baby/Child Exams/Immunizations & Adult Physical Exams/Immunizations /Routine GYN Exams/Routine Mammograms (Age/Frequency Schedules Apply) Routine Mammograms (Age/Frequency Schedules Apply) 80% Inpatient Hospital 80% Outpatient Surgery 80% Emergency Room (Copay if admitted) 80% Urgent Care 80% Outpatient Physical/Occupational Therapy and Chiropractic Services (40 visits per calendar year.) and Outpatient Speech Therapy (12 visits per calendar year.) (In and out-of-network combined.) Prescription Drugs Retail: per 30-day supply Mail Order: two times retail copay, day supply, includes insulin 90-Day Rx Transition of Coverage (TOC) for Prior Certification(4) $0 copay, deductible $0 copay, deductible 80% $10/$40/$65 Included M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 13

16 I l l i n o i s p l a n G U I D E A e t n a S m a l l G r o u p H M O M e d i c a l P l a n s Aetna Plan Options HMO 1 (10/10) + Member Benefits PCP Referrals Required Plan Coinsurance 70% Calendar Year Deductible Calendar Year Out-of-Pocket Maximum 1 Lifetime Maximum Benefit Primary Physician Office Visit Specialist Office Visit In-Network Yes $0 per member $0 family $1,500 per member $3,000 family Unlimited Outpatient Lab and X-Ray 70% Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET Scans; precertification required) Well Baby/Child Exams/Immunizations & Adult Physical Exams/Immunizations /Routine GYN Exams/Routine Mammograms (Age/Frequency Schedules Apply) Routine Eye Exam (One exam per 24 months.) $25 copay $40 copay 70% $0 copay $0 copay Inpatient Hospital 70% Outpatient Surgery 70% Emergency Room (Copay if admitted) Urgent Care Outpatient Physical/Occupational Therapy/Speech Therapy (60 visits per calendar year.) and Chiropractic Prescription Drugs (Includes insulin) Retail and Mail Order: up to 90-day supply 90-Day Rx Transition of Coverage (TOC) for Step Therapy and Prior Certification 2 $200 copay $50 copay $40 copay $15/$35/$60 30-day supply $30/$70/$ day supply Included For footnotes, see page

17 I l l i n o i s A e t n a S m a l l G r o u p M e d i c a l P l a n s I L C o m m u n i t y P l a n S M O p t i o n s Aetna Plan Options IL Community Plan SM $500 80/50/50 (10/10) + Member Benefits Route 1: Community Network Route 2: Managed Choice Network PCP Referrals Required No No No Plan Coinsurance (applies to most services) 80% 50% 50% Calendar Year Deductible 2 Calendar Year Coinsurance Maximum 3 (Excludes deductible, copayments, member coinsurance payments for DME, and copayments for prescription drugs) Lifetime Maximum Benefit Primary Physician Office Visit Specialist Office Visit $500 per member $1,500 family $2,000 per member $6,000 family $20 copay, deductible $40 copay, deductible $5,000 per member $15,000 family $10,000 per member $30,000 family Unlimited $40 copay, deductible $60 copay, deductible Outpatient Services Lab $0 copay, deductible $60 copay, deductible Outpatient Services X-Ray 80% 50% 50% Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET Scans; precertification required) Well Baby/Child Exams/Immunizations & Adult Physical Exams/Immunizations /Routine GYN Exams/Routine Mammograms (Age/Frequency Schedules Apply) Routine Eye Exam (One exam per 24 months. Routes 1, 2 and 3 combined.) Route 3: All Other Providers 1 $10,000 per member $30,000 family $20,000 per member $60,000 family 50% 50% 50% 80% 50% 50% $0 copay, deductible $0 copay, deductible 50% $0 copay, deductible $0 copay, deductible 50% Inpatient Hospital 80% 50% 50% Outpatient Surgery 80% 50% 50% Emergency Room (Copay if admitted.) Urgent Care Outpatient Physical/Occupational Therapy and Chiropractic Services (40 visits per calendar year.) and Outpatient Speech Therapy (12 visits per calendar year.) (Routes 1, 2 and 3 combined.) Prescription Drugs (Includes insulin) Retail: per 30-day supply Mail Order: two times retail copay, day supply $50 copay, deductible $250 copay, deductible $50 copay, deductible 50% 80% 50% 50% $20/$50/$70 70% after $20/$50/$70 90-Day Rx Transition of Coverage Included Included (TOC) for Prior Certification 4 For footnotes, see page 17. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 15

18 I l l i n o i s p l a n G U I D E I l l i n o i s A e t n a S m a l l G r o u p M e d i c a l P l a n s I L C o m m u n i t y P l a n S M O p t i o n s Aetna Plan Options IL Community Plan SM $1,000 80/50/50 (10/10) + Member Benefits Route 1: Community Network Route 2: Managed Choice Network PCP Referrals Required No No No Plan Coinsurance (applies to most services) 80% 50% 50% Calendar Year Deductible 2 Calendar Year Coinsurance Maximum 3 (Excludes deductible, copayments, member coinsurance payments for DME, and copayments for prescription drugs) Lifetime Maximum Benefit Primary Physician Office Visit Specialist Office Visit Outpatient Services Lab $1,000 per member $3,000 family $2,000 per member $6,000 family $30 copay, deductible $50 copay, deductible $0 copay, deductible $5,000 per member $15,000 family $10,000 per member $30,000 family Unlimited $50 copay, deductible $70 copay, deductible $70 copay, deductible Outpatient Services X-Ray 80% 50% 50% Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET Scans; precertification required) Well Baby/Child Exams/Immunizations & Adult Physical Exams/Immunizations /Routine GYN Exams/Routine Mammograms (Age/Frequency Schedules Apply) Routine Eye Exam (One exam per 24 months. Routes 1, 2 and 3 combined.) Route 3: All Other Providers 1 $10,000 per member $30,000 family $20,000 per member $60,000 family 50% 50% 50% 80% 50% 50% $0 copay, deductible $0 copay, deductible $0 copay, deductible $0 copay, deductible Inpatient Hospital 80% 50% 50% Outpatient Surgery 80% 50% 50% Emergency Room (Copay if admitted.) Urgent Care Outpatient Physical/Occupational Therapy and Chiropractic Services (40 visits per calendar year.) and Outpatient Speech Therapy (12 visits per calendar year.) (Routes 1, 2 and 3 combined.) Prescription Drugs (Includes insulin) Retail: per 30-day supply Mail Order: two times retail copay, day supply $50 copay, deductible $250 copay, deductible $50 copay, deductible 50% 50% 50% 80% 50% 50% $20/$50/$70 70% after $20/$50/$70 90-Day Rx Transition of Coverage Included Included (TOC) for Prior Certification 4 For footnotes, see page

19 F o O t n o t e s The federal health care reform legislation known as the Patient Protection and Affordable Care Act was signed into law on March 23, A number of new reforms are effective September 23, 2010, including coverage for dependents up to age 26, elimination of lifetime benefit dollar maximums, restriction of annual dollar maximums on essential health benefits, removal of cost sharing for preventive services and elimination of pre-existing condition exclusions for dependent children under 19 years of age. Your Aetna Avenue benefit program does comply with the new reform legislation. + This is a partial description of benefits available; for more information, refer to the specific plan design summary. The dollar amount copayments indicate what the member is required to pay and the percentage amounts indicate what Aetna is required to pay. The deductible applies to all medical benefits unless otherwise stated. 1 You may choose providers in Aetna s network (physicians and facilities) or you may visit an out-of-network provider. Typically, you will pay substantially more money out of your own pocket if you choose to use an out-of-network doctor. The out-of-network provider will be paid based on Aetna s recognized charge. This is not the same as the billed charge from the doctor. Aetna pays a percentage of the recognized charge, as defined in your plan. You may have to pay the difference between the out-of-network provider s billed charge and Aetna s recognized charge, plus any coinsurance and deductibles due under the plan. Note that any amount the doctor bills you above Aetna s recognized charge does not count toward your deductible or out-of-pocket maximums. For out-of-network physicians and other out-of-network providers, the recognized charge is based on the Aetna Market Fee Schedule (also referred to as Aetna Out-of-Network Rates), which are Aetna s standard rates used to begin contract negotiations with providers who participate in our network. Since not all network doctors contract at standard rates, our payment to an out-of-network provider may be based on rates lower than we pay to providers in our network. For out-of-network hospitals and other out-of-network facilities the recognized charge is based on the Aetna Facility Fee Schedule. This benefit applies when you choose to get care out of network. When you have no choice in the doctors you see (for example, an emergency room visit after a car accident), your deductible and coinsurance for the in-network level of benefits will be applied, and you should contact Aetna if your doctor asks you to pay more. Generally, you are not responsible for any outstanding balance billed by your doctors in an emergency situation unless you have an Open Choice PPO plan. 2 Once the family deductible is met, all family members will be considered as having met their deductible for the remainder of the calendar year. No one family member may contribute more than the individual deductible amount to the family deductible. In and out-of-network accumulate separately. 2 Once the family coinsurance or out-of-pocket maximum is met, all family members will be considered as having met their coinsurance or out-of-pocket maximum for the remainder of the calendar year. No one family member may contribute more than the individual coinsurance or out-of-pocket maximum amount to the family coinsurance or out-of-pocket maximum. In and out-of-network accumulate separately. 4 Transition of Coverage for Prior Authorization helps members of new groups to transition to Aetna by providing a 90-calendar day opportunity, beginning on the group s initial effective date, during which time prior authorization requirements will not apply to certain drugs. One the 90 calendar days have expired, prior authorization edits will apply to all drugs requiring prior authorization as listed in the formulary guide. Members who have claims paid for a drug requiring prior authorization during the Transition of Coverage period may continue to receive this drug after the 90 calendar days and will not be required to obtain a prior authorization. Some benefits are subject to limitations or visit maximums. Members or providers may be required to precertify, or obtain prior approval for certain services, such as non-emergency hospital care. Note: For a summary list of Limitations and Exclusions, refer to pages Please refer to Aetna s Producer World web site at for more detailed small business benefit descriptions. Or for more information, please contact your licensed agent or Aetna Sales Representative. HMO Plans: + This is a partial description of benefits available; for more information, refer to the specific plan design summary. The dollar amount copayments indicate what the member is required to pay and the percentage amounts indicate what Aetna is required to pay. 1 Certain member cost-sharing elements may not apply toward the Calendar Year Out-of-Pocket Maximum, such as payments for prescription drugs and DME. 2 Transition of Coverage for Prior Authorization helps members of new groups to transition to Aetna by providing a 90-calendar day opportunity, beginning on the group s initial effective date, during which time step therapy and prior authorization requirements will not apply to certain drugs. One the 90 calendar days have expired, step therapy and prior authorization edits will apply to all drugs requiring prior authorization as listed in the formulary guide. Members who have claims paid for a drug requiring step therapy or prior authorization during the Transition of Coverage period may continue to receive this drug after the 90 calendar days and will not be required to obtain a prior authorization. Some benefits are subject to limitations or visit maximums. Members or providers may be required to precertify, or obtain prior approval for certain services, such as non-emergency hospital care. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 17

20 I l l i n o i s p l a n G U I D E Aetna Avenue d e n ta l Ov e r v i e w A e t n a D e n ta l p l a n s Small business decision makers can choose from a variety of plan design options that help you offer a dental benefits and dental insurance plan that s just right for your employees. The Mouth Matters SM Research shows that more than 90 percent of all medical illnesses are detectable in the mouth and that 75 percent of people over the age of 35 have periodontal (gum) disease. 1 Untreated oral diseases can have a big impact on the quality of life. This means that a dentist may be the first health care provider to diagnose a health problem! Aetna Dental/Medical Integration SM program, available at no additional charge to plan sponsors that have both medical and dental coverages with Aetna, focuses on those who are pregnant or have diabetes, coronary artery disease (heart disease) or cerebrovascular disease (stroke) and have not had a recent dental visit. We proactively educate those at-risk members about the impact oral health care can have on their condition. Our member outreach has been proven to successfully motivate those at-risk members who do not normally seek dental care to visit the dentist. 2 Once at the dentist, these at-risk members will receive enhanced dental benefits including an extra cleaning and full coverage for certain periodontal services. The Dental Maintenance Organization (DMO )* Members select a primary care dentist to coordinate their care from the available managed dental network. Each family member may choose a different primary care dentist and may switch dentists at any time via Aetna Navigator or with a call to Member Services. If specialty care is needed, a member s primary care dentist can refer the member to a participating specialist. However, members may visit orthodontists without a referral. There are virtually no claim forms to file, and benefits are not subject to deductibles or annual maximums. 1 The professional entity, Academy of General Dentistry, Dental/medical integration, Improved oral health can lead to a better overall health Smart Business Chicago (1/07). * In Illinois, DMO plans provide limited out-of-network benefits. However, in order to receive maximum benefits, members must select and have care coordinated by a participating primary care dentist. Illinois DMO is not an HMO. DMI may not be available in all states. 18

21 Preferred Provider Organization (PPO) plan Members can choose a dentist who participates in the network or choose a licensed dentist who does not. Participating dentists have agreed to offer our members services at a negotiated rate and will not balance-bill members.*** PPO Max plan While the PPO Max dental insurance plan uses the PPO network, when members use out-of-network dentists the service will be covered based on the PPO fee schedule, rather than the reasonable and customary charge. The member will share in more of the costs and may be balance-billed. This plan offers members a quality dental insurance plan with a significantly lower premium that encourages in-network usage. Freedom-of-Choice plan design option Get maximum flexibility with our twoin-one dental plan design. The Freedomof-Choice plan design option provides the administrative ease of one plan, yet members get to choose between the DMO* and PPO Max plans on a monthly basis. One blended rate is paid. Members may switch between the plans on a monthly basis by calling Member Services. Plan changes must be made by the 15th of the month to be effective the following month. Dual Option** plan In the Dual Option plan design the DMO* may be packaged with any one of the PPO plans. Employees may choose between the DMO* and PPO offerings at annual enrollment. Voluntary Dental option The Voluntary Dental option provides a solution to meet the individual needs of members in the face of rising health care costs. Administration is easy, and members benefit from low group rates and the convenience of payroll deductions. Employers choose how the plan is funded. It can be entirely memberpaid or employers can contribute up to 50 percent. * In Illinois, DMO plans provide limited out-of-network benefits. However, in order to receive maximum benefits, members must select and have care coordinated by a participating primary care dentist. Illinois DMO is not an HMO. ** Dual Option does not apply to Preventive and Voluntary Dental plans. ***Discounts for non-covered services may not be available. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 19

22 I l l i n o i s p l a n G U I D E S m a l l G r o u p D e n ta l P l a n s ( E f f e c t i v e 1 0 / 0 1 / 1 0 ) Available With an Aetna Medical Plan to Groups with 2-50 Eligible Employees Available Without Medical Plan to Groups with 3-50 Eligible Employees Option 1 Preventive Care PPO Option 2 DMO Access PPO Plan Preventive Care Copay Plan 42 DMO Plan 100/90/60 Option 3 Freedom of Choice Monthly selection between the DMO and the PPO Office Visit Copay N/A $10 $10 N/A Annual Deductible per Member does not apply to Diagnostic & Preventive Services PPO Max Plan 100/70/50 None None None $50; 3X Family Maximum Annual Maximum Benefit None Unlimited Unlimited $1,000 Diagnostic Services Oral Exams Periodic oral exam 100% No Charge 100% 100% Comprehensive oral exam 100% No Charge 100% 100% Problem-focused oral exam 100% No Charge 100% 100% X-rays Bitewing single film 100% No Charge 100% 100% Complete series 100% No Charge 100% 100% Preventive Services Adult Cleaning 100% No Charge 100% 100% Child Cleaning 100% No Charge 100% 100% Sealants per tooth 100% $10 100% 100% Fluoride application with cleaning 100% No Charge 100% 100% Space maintainers 100% $ % 100% Basic Services Amalgam filling 2 surfaces Not covered $32 90% 70% Resin filling 2 surfaces, anterior Not covered $55 90% 70% Oral Surgery Extraction exposed root or erupted tooth Not covered $30 90% 70% Extraction of impacted tooth soft tissue Not covered $80 90% 70% *Major Services Complete upper denture Not covered $500 60% 50% Partial upper denture (resin base) Not covered $513 60% 50% Crown Porcelain with noble metal 1 Not covered $488 60% 50% Pontic Porcelain with noble metal 1 Not covered $488 60% 50% Inlay Metallic (3 or more surfaces) Not covered $463 60% 50% Oral Surgery Removal of impacted tooth partially bony Not covered $175 60% 50% Endodontic Services Bicuspid root canal therapy Not covered $195 90% 50% Molar root canal therapy Not covered $435 60% 50% Periodontic Services Scaling & root planing per quadrant Not covered $65 90% 50% Osseous surgery per quadrant Not covered $445 60% 50% *Orthodontic Services Not covered $2300 copay $2300 copay Not covered Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply Does not apply *Coverage Waiting Period: Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Does not apply to the DMO in Plan Options 2, 3 & 10 or the PPO in Plan Options 1 & 9. Fixed Dollar Copay amounts on the DMO in Plan Options 2, 3 & 10 are member responsibility. 1 There will be an additional patient charge for the actual cost for gold/high noble metal for these procedures for the DMO in Plan Option 2. The DMO in Plan Options 2 & 10 can be offered with any one of the PPO plans in Plan Options 4-8 and 11 in a Dual Option package. Access to negotiated discounts: On the PPO in Plan Options 1,3-9 & 11, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. Discounts are not insurance. Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the DMO in Plan Options 2 & 3 and on the PPO in Plan Options 7, 8 & 11. Plan Options 3, 4, 9 & 11; PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the Plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. Out-of-Network plan payments are limited by geographic area on Plan Options 1, 5, 6 & 8 prevailing fees at the 80th percentile and the 90th percentile on Plan Option 7. Orthodontic coverage is available only to groups with 10 or more eligibles and to dependent children only. DMO Access: Apart from the DMO network and DMO plan of benefits, members under this plan also have access to the Aetna Dental Access Network. This network provides access to providers who participate in the Aetna Dental Access Network and have agreed to charge a negotiated discounted fee. Members can access this network for any service. However, the DMO benefits do not apply. In situations where the Dentist participates in both the Aetna Dental Access Network and the Aetna DMO network, DMO benefits take precedence over all other discounts including discounts through the Aetna Dental Access network. Aetna Dental Access Network is not insurance or a benefits plan. It only provides access to discounted fees for dental services obtained from providers who participate in the Aetna Dental Access network. Members are solely responsible for all charges incurred using this access, and are expected to make payment to the provider at the time of treatment. Above list of covered services is representative. Full list with limitations as determined by Aetna appears in the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page