AETNA HEALTH INC. 980 Jolly Road Blue Bell, PA (MARYLAND) CERTIFICATE OF COVERAGE

Transcription

1 Plan Name: MD Gold HMO % MDN AETNA HEALTH INC. 980 Jolly Road Blue Bell, PA (MARYLAND) CERTIFICATE OF COVERAGE This Certificate of Coverage ("Certificate") is part of the Group Agreement ("Group Agreement") between Aetna Health Inc., hereinafter referred to as Aetna, and the Contract Holder. The Group Agreement determines the terms and conditions of coverage. The Certificate describes covered health care benefits. Provisions of this Certificate include the Schedule of Benefits, and any amendments, endorsements, inserts, or attachments. Amendments, endorsements, inserts, or attachments may be delivered with the Certificate or added thereafter. Aetna agrees with the Contract Holder to provide coverage in accordance with the conditions, rights, and privileges as set forth in this Certificate. Members covered under this Certificate are subject to all the conditions and provisions of the Group Agreement. Coverage is not provided for any services received before coverage starts or after coverage ends, except as shown in the Continuation and Extension of Benefits section of this Certificate. Certain words have specific meanings when used in this Certificate. The defined terms appear in bold type with initial capital letters. The definitions of those terms are found in the Definitions section of this Certificate. This Certificate is not in lieu of insurance for Workers Compensation. This Certificate is governed by applicable federal law and the laws of Maryland. Coverage under this Plan is non-occupational. Only non-occupational injuries and non-occupational illnesses are covered under this Plan. If you are an owner of the company that applied for coverage under this Plan and no other sources of coverage or reimbursement are available to you for the services or supplies, then you will also be covered for occupational injuries and occupational illnesses. Other sources of coverage or reimbursement may include workers compensation, or an occupational illness or similar program under local, state or federal law. A source of coverage or reimbursement will be considered available to you even if you waived your right to payment from that source. If you are also covered under a workers compensation law or similar law, and submit proof that you are not covered for a particular illness or injury under such law, that illness or injury will be considered non-occupational regardless of cause. REFERENCE TO YOU OR YOUR IN THIS CERTIFICATE MEANS A MEMBER. READ THIS ENTIRE CERTIFICATE CAREFULLY. IT DESCRIBES THE RIGHTS AND OBLIGATIONS OF MEMBERS AND AETNA. IT IS THE CONTRACT HOLDER S AND THE MEMBER'S RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CERTIFICATE. IN SOME CIRCUMSTANCES, CERTAIN MEDICAL SERVICES ARE NOT COVERED OR MAY REQUIRE PRECERTIFICATION BY AETNA. -1-

2 NO SERVICES ARE COVERED UNDER THIS CERTIFICATE IN THE ABSENCE OF PAYMENT OF CURRENT PREMIUMS SUBJECT TO THE GRACE PERIOD AND THE PREMIUMS SECTION OF THE GROUP AGREEMENT. THIS CERTIFICATE APPLIES TO COVERAGE ONLY AND DOES NOT RESTRICT A MEMBER S ABILITY TO RECEIVE HEALTH CARE SERVICES THAT ARE NOT, OR MIGHT NOT BE, COVERED BENEFITS UNDER THIS CERTIFICATE. PARTICIPATING PROVIDERS, NON-PARTICIPATING PROVIDERS, INSTITUTIONS, FACILITIES OR AGENCIES ARE NEITHER AGENTS NOR EMPLOYEES OF AETNA. NOTE: MEMBERS SHOULD REFER TO THE ADMINISTRATIVE COMPLAINT, GRIEVANCE AND APPEAL PROCEDURE DESCRIBED IN THIS CERTIFICATE. IF, AFTER READING THIS PROCEDURE, THEY WANT TO CONTACT THE MARYLAND INSURANCE ADMINISTRATION, THEY MAY DO SO AT THE FOLLOWING ADDRESS: Maryland Insurance Administration Inquiry and Investigation Unit Life & Health 200 St. Paul Place, Suite 2700 Baltimore, Maryland Fax: (410) Phone: (410) or (800) (toll free) TDD Users: (800) (toll free) Important Unless otherwise specifically provided, no Member has the right to receive the benefits of this Plan for health care services or supplies furnished following termination of coverage. Benefits of this Plan are available only for services or supplies furnished during the term the coverage is in effect and while the individual claiming the benefits is actually covered by the Group Agreement. Benefits can be received after coverage terminates under the Group Agreement to the extent described in the Continuation and Extension of Benefit provision. Benefits may be modified during the term of this Plan as specifically provided under the terms of the Group Agreement or upon renewal. If benefits are modified, the revised benefits (including any reduction in benefits or elimination of benefits) apply for services or supplies furnished on or after the effective date of the modification. There is no vested right to receive the benefits of the Group Agreement. -2-

3 TABLE OF CONTENTS Section Page Aetna Procedure 4 Eligibility and Enrollment 10 Covered Benefits 18 Exclusions and Limitations 58 Termination of Coverage 70 Continuation and Extension of Benefits 72 Administrative Complaint, Grievance And Appeal Procedure 76 Coordination of Benefits 89 Subrogation and Right of Recovery 96 Responsibility of Members 99 General Provisions 100 Definitions

4 AETNA PROCEDURE Selecting a Participating Primary Care Physician At the time of enrollment, each Member is required to select a Participating Primary Care Physician (PCP) from Aetna s Directory of Participating Providers to access Covered Benefits as described in this Certificate. The choice of a PCP is made solely by the Member. If the Member is a minor or otherwise incapable of selecting a PCP, the Subscriber should select a PCP on the Member s behalf. Until a PCP is selected, benefits will be limited to coverage for Medical Emergency and Urgent care. The Primary Care Physician The PCP coordinates a Member's medical care, as appropriate, either by providing treatment or by issuing Referrals to direct the Member to another Participating Provider. A Member may receive a standing Referral from their PCP to a Participating Specialist if: The Member s PCP, in consultation with the Participating Specialist, determines that the Member needs continuing care from the Participating Specialist; The Member has a condition or disease that is: (i) life-threatening, degenerative, chronic, or disabling and (ii) requires specialized medical care; and The Participating Specialist has expertise in treating the life-threatening, degenerative, chronic or disabling condition or disease. The standing Referral shall be made in accordance with a written plan for Covered Benefits developed by the PCP, Participating Specialist, and Member. The treatment plan may limit the number of visits to the Participating Specialist, and the period of time in which the visits to the Participating Specialist are authorized. A Member who is pregnant can also receive a standing Referral to a Participating obstetrician for the primary management of the Member s pregnancy, including the issuance of Referrals in accordance with Aetna s policies and procedures, through the post-partum period. A written treatment plan is not required when a standing Referral is provided to an obstetrician for the primary management of the Member s pregnancy. The PCP can also order lab tests and x-rays, prescribe medicines or therapies, and arrange hospitalization. Except in a Medical Emergency or for certain direct access Specialist benefits as described in this Certificate, only those services which are provided by or referred by a Member s PCP will be covered. Covered Benefits are described in the Covered Benefits section of this Certificate. It is a Member s responsibility to consult with the PCP in all matters regarding the Member s medical care. Certain PCP offices are affiliated with integrated delivery systems or other provider groups (i.e., Independent Practice Associations and Physician-Hospital Organizations), and Members who select these PCPs will generally be referred to Specialists and Hospitals within that system or group. However, if the group does not include a Provider qualified to meet the Member s medical needs, the Member may request to have services provided by nonaffiliated Providers. If the Member s PCP performs, suggests, or recommends a Member for a course of treatment that includes services that are not Covered Benefits, the entire cost of any such non-covered services will be the Member s responsibility. -4-

5 Covered Benefits also include E-visits. Registration with an internet service vendor may be required. Information about Participating Providers who conduct E-visits may be found in the provider Directory, online in DocFind on or by calling the number on your Member identification card. Availability of Providers Aetna cannot guarantee the availability or continued participation of a particular Provider. Either Aetna or any Participating Provider may terminate the Provider contract or limit the number of Members that will be accepted as patients. If the PCP initially selected cannot accept additional patients, the Member will be notified and given an opportunity to make another PCP selection. The Member must then cooperate with Aetna to select another PCP. Until a PCP is selected, benefits are limited to coverage for Medical Emergency and Urgent Care. In the event a Covered Benefit cannot be provided to a Member by any Specialist or Non-Physician Specialist in Aetna s Participating Provider panel, Aetna will provide the Member with a Referral to a non-participating Specialist or Non-Physician Specialist if: the Member is diagnosed with a condition or disease that requires specialized medical care; and Aetna does not have a Specialist or Non-Physician Specialist in its Participating Provider panel with the professional training and expertise to treat the Member s condition or disease; or Aetna cannot provide reasonable access to a Participating Specialist or Non-Physician Specialist with the professional training and expertise to treat the condition or disease without unreasonable delay or travel. In those instances where Aetna provides the Member with a Referral to a non-participating Specialist or Non-Physician Specialist (as described above) Aetna will calculate any Deductible, Copayment amount, or Coinsurance payable by the Member for the services received by the non-participating Specialist or Non-Physician Specialist, as if the services received were provided by a Participating Provider. In the event a Member is participating in a controlled clinical trial, Aetna will provide the Member with a Referral to a non-participating Provider, whether in or outside the Service Area, if the Member obtains a Referral from their PCP and authorization from Aetna to participate in the controlled clinical trial in advance. Changing a PCP You may change your PCP at any time by calling Member Services at the toll-free telephone number listed on the Member s identification card or by written or electronic submission of Aetna s change form. A Member may contact Aetna to request a change form or for assistance in completing that form. The change will become effective upon Aetna s receipt and approval of the request. -5-

6 Ongoing Reviews Aetna conducts ongoing reviews of those services and supplies which are recommended or provided by Health Professionals to determine whether such services and supplies are Covered Benefits under this Certificate. If Aetna determines that the recommended services and supplies are not Covered Benefits, the Member will be notified. If a Member wishes to appeal such determination, the Member may then contact Aetna to seek a review of the determination. Please refer to the Administrative Complaint, Grievance And Appeal Procedure section of this Certificate. The Referral Process Except for PCP, direct access and emergency or urgent care services, you must have a prior written, electronic or, if applicable, verbal Referral from your PCP to receive coverage for all services and any necessary follow-up treatment. How Referrals Work Here are some important points to remember: When your PCP determines that your treatment should be provided by a Specialist or Hospital or other health care professional, you will receive a written, electronic or, if applicable, a verbal Referral. The Referral will be good for 60 days, as long as you remain covered under the plan. Go over the Referral with your PCP. Make sure you understand what types of services have been recommended and why. When you visit the provider or facility, bring the Referral (or check in advance to verify that they have received the written, electronic or, if applicable, a verbal Referral). Without it, you will not receive coverage even if you receive your treatment from a Participating Provider. Certain services such as inpatient stays, outpatient surgery and certain other medical procedures and tests require both a PCP referral and precertification. Precertification verifies that the recommended treatment is a Covered Benefit as described in the Covered Benefit section. This is not a guarantee that benefits will be payable if, for example, it is determined at the time the claim is submitted that you were not eligible for benefits at that time. Your PCP or other Participating Providers are responsible for obtaining precertification for you. You cannot request a Referral from your PCP after you have received services or supplies from a Specialist or Hospital. If a service or supply that you need is not available from a Participating Provider, your PCP may refer you to a Non-Participating Provider. Your PCP or other network Physician must get pre-approval from Aetna for services from Non-Participating Providers so that Covered Benefits can be covered at the network level of benefits as shown in your Schedule of Benefits. -6-

7 Ongoing Specialist Care If you have a condition which requires ongoing care from a Specialist, you or your Physician may request a standing Referral to such Specialist. Circumstances which may warrant this type of Referral include, but are not limited to, a condition of disease that is life threatening, degenerative, chronic or disabling. You should initially make this Request through your PCP. If Aetna, the PCP and/or Specialist, in consultation with a medical director, determine that such a standing Referral is appropriate, Aetna will authorize such a Referral to Specialist who is a Participating Provider. Aetna is not required to permit you to elect a Specialist who is a Non-Participating Provider, unless such a Specialist is not available within the network. Any authorized Referral shall be made pursuant to a treatment plan approved by Aetna in consultation with the PCP, the Specialist and you, or your designee. The treatment plan may limit the number of visits or the period during which the visits are authorized and may require the Specialist to provide the PCP with regular updates on the specialty care provided, as well as all necessary medical information. A Member who is pregnant can also receive a standing Referral to a Participating obstetrician for the primary management of the Member s pregnancy, including the issuance of Referrals in accordance with Aetna s policies and procedures, through the post-partum period. A written treatment plan is not required when a standing Referral is provided to an obstetrician for the primary management of the Member s pregnancy. When You Don t Need a PCP Referral You don t need a PCP referral for: Emergency care See Coverage for Emergency Medical Conditions. Urgent care See Coverage for Urgent Conditions. Direct access services Services from Participating Providers for which the Referral is not required. Certain routine and preventive services do not require a Referral under the plan when accessed in accordance with the age and frequency limitations outlined in the Covered Benefits section and the Schedule of Benefits. Refer to the Covered Benefits section for information on when these benefits are covered. You can directly access these Participating Specialists for: - Gynecological and Pap smear visits, including related items and services - Obstetrical services - Annual screening mammogram for age-eligible women - Routine prenatal care - Routine eye exams, including refraction - Preventive Dental Care for your dependents under the age of 19 Precertification Certain services and supplies under this Certificate may require precertification by Aetna to determine if they are Covered Benefits under this Certificate. -7-

8 Continuity of Care Existing Enrollees The following applies when your Hospital or Physician: Stops participation with Aetna as a Participating Provider for reasons other than imminent harm to patient care, a determination of fraud, or a final disciplinary action by a state licensing board that impairs the heath professional s ability to practice; Aetna will continue coverage for an ongoing course of treatment with your current Hospital or Physician during a transitional period. Coverage shall continue for up to 90 days from the date of notice to you from Aetna that the provider terminated participation with Aetna as a Participating Provider. If you have entered the second trimester of pregnancy, the transitional period will include the time required for postpartum care directly related to the delivery. During this transitional period the Hospital or Physician agrees: To accept reimbursement at the Negotiated Charge and cost sharing applicable prior to the start of the transitional period as payment in full; To adhere to quality standards and to provide medical information related to such care; and To adhere to Aetna s policy and procedures. This provision shall not be construed to require Aetna to provide coverage for benefits not otherwise covered under this Certificate. With regards to the continuity of coverage provisions described above, the notice of the event provided to you by Aetna will include specific instructions on how to request continuity of coverage during the transitional period. New Enrollees If you are a new enrollee and your current provider does not have a contract with Aetna, you may continue an ongoing course of treatment with your current provider for the following conditions: acute conditions; serious chronic conditions; pregnancy; mental health conditions and substance use disorders; and any other condition for which the provider and Aetna reach agreement, for a transitional period of: up to 90 days; and in the case of pregnancy, the duration of the three trimesters of pregnancy, including the period of time that postpartum care directly related to the delivery is provided; beginning on the effective date of enrollment. -8-

9 If you are an individual transitioning from the Maryland Medical Assistance Program to Aetna, and you are currently receiving behavioral health or dental benefits under that program, which have been authorized by the Maryland Medical Assistance Program s third-party administrator, or you are an individual transitioning from another carrier or managed care organization to Aetna, then, at your or your parent s, guardian s, designee s or health care provider s request, Aetna will accept the third-party administrators, relinquishing carriers or managed care organizations preauthorization for the procedures, treatments, medications, or services you are receiving and which are covered by Aetna for the lesser of the course of treatment or 90 days; and the duration of the three trimesters of a pregnancy and the initial post-partum visit. The third-party administrator, relinquishing carrier or managed care organization shall provide Aetna with a copy of the pre-authorization within 10 days of your request. You need to complete a Transition of Coverage Request form and send it to Aetna. Contact Member Services at the number on the back of your ID card for a copy of this form. If authorized by Aetna, coverage will be provided for the transitional period. This provision shall not be construed to require Aetna to provide coverage for benefits not otherwise covered under this Certificate. -9-

10 ELIGIBILITY AND ENROLLMENT Eligibility Subscriber To be eligible to enroll as a Subscriber, an individual must: Meet all applicable eligibility requirements agreed upon by the Contract Holder and Aetna; and Live or work in the Service Area Determining if You Are in an Eligible Class You are in an eligible class if: You are a regular full-time employee. A full-time employee means, with respect to a calendar month, an employee of a small employer who works, on average, at least 30 hours per week. A full-time employee does not include a seasonal employee as defined in federal law. You are a part-time employee and your employer has elects to offer coverage to part-time employees. A part time employee means an employee who: Has a normal workweek of a least 17.5 hours; and Is not a full-time employee. Determining When You Become Eligible You become eligible for the plan on your eligibility date, which is determined as follows. On the Effective Date of the Plan If you are in an Eligible Class on the effective date of your plan, your Eligibility Date is the effective date of this Plan or, if later, the date you complete any applicable Waiting Period. Your employer determines the criteria that is used to define the Eligible Class for coverage under this Certificate. Such criteria are based solely upon conditions related to your employment. See your employer for details. After the Effective Date of the Plan If you are in an Eligible Class on the date of hire, your Eligibility Date is your date of hire or, if later, the date you complete the Waiting Period, if any, required by your employer. Your employer determines the criteria that are used to define the Eligible Class and Waiting Period for coverage under this Certificate. Such criteria are based solely upon conditions related to your employment. See your employer for details. Waiting Period Once you enter an eligible class, you will need to complete the waiting period, if any, before your coverage under this plan begins. A Waiting Period may not exceed 90 days. -10-

11 Obtaining Coverage for Dependents To be eligible to enroll as a Covered Dependent, the dependent must be: Your legal spouse; or Your domestic partner; or Your dependent children; or Dependent children of your domestic partner. Coverage for Dependent Children To be eligible for coverage, a dependent child must be: Under 26 years of age. Covered Benefits for a Covered Dependent who is not capable of self-support due to mental or physical incapacity will be continued past the maximum age for a child. An eligible dependent child includes: Your biological children. Your stepchildren. Your legally adopted children, including any children placed with you for adoption. Your foster children. Any children for whom you are responsible under court order or for whom guardianship has been granted by court or testamentary appointment; Your grandchildren. An eligible dependent of your covered domestic partner Any child whose parent is your child and your child is covered as a dependent under this Plan. Any other child with whom you have a parent-child relationship. No individual may be covered both as an employee and dependent and no individual may be covered as a dependent of more than one employee. A Member who resides outside the Service Area is required to choose a PCP and return to the Service Area for Covered Benefits. The only services covered outside the Service Area are Emergency Services, Urgent Care and covered clinical trials. Coverage for a Domestic Partner Your domestic partner may be covered. To be eligible for coverage, you and your domestic partner will need to show the following as proof of the domestic partnership relationship. An affidavit signed by both the Subscriber and the domestic partner that includes the following attestations. - Both individuals are 18 or older; - Neither individual is related to the other by blood or marriage within four degrees of consanguinity under civil law rule. - Neither individual is married or in a civil union or domestic partnership with another individual; -11-

12 - Both individuals have been financially interdependent for at least 6 consecutive months in which each individual contributes to some extent to the other individual s maintenance and support with the intention of remaining in the relation indefinitely; and - Both individuals share common primary residence. One of the following documents as proof of primary residence. - Common ownership of the primary residence via joint deed or mortgage agreement; - Common leasehold interest in the primary residence; - Driver s license or State-issued identification listing a common address; or - Utility or other household bills with both the name of the Subscriber and the name of the domestic partner appearing. One of the following documents as proof of financial interdependence. - Joint bank account or credit account; - Designation as a primary beneficiary for life insurance or retirement benefits of the domestic partner; - Designation as primary beneficiary under the domestic partner s will; - Mutual assignments of valid durable powers of attorney under Maryland Estates and Trusts law; - Mutual valid written advanced directives under Maryland law, approving the other domestic partner as health care agent; - Joint ownership or holding of investments; or - Joint ownership or lease of a motor vehicle. How And When To Enroll Enrollment Unless otherwise noted, an eligible individual and any eligible dependents may enroll in Aetna regardless of health status, age, or requirements for health services within 31 days from the eligibility date. Newly Eligible Individuals and Eligible Dependents An eligible individual and any eligible dependents may enroll within 31 days of the eligibility date. Annual Open Enrollment Period A period of 30 days during which eligible individuals or dependents who are eligible for enrollment but do not enroll as stated above, may be enrolled during the initial and subsequent Annual Open Enrollment Periods upon submission of complete enrollment information. During the Annual Open Enrollment Period each eligible individual or dependent may: Enroll in the Plan. Discontinue enrollment. Change enrollment from one plan offered by the Contract Holder to a different plan offered by the Contract Holder. -12-

13 Enrollment of Newly Eligible Dependents Newborn Children A newborn child is covered for 31 days from the date of birth. If coverage requires the payment of an additional Premium for a Covered Dependent, to continue coverage beyond this initial period, the child must be enrolled in Aetna within the initial 31 day period. If coverage does not require the payment of an additional Premium for a Covered Dependent, the Subscriber is requested to enroll the child within 31 days after the date of birth. The coverage for newly born, adopted children, and children placed for adoption consists of coverage of injury and sickness, including the necessary care and treatment of congenital defects and birth abnormalities, and within the limits of this Certificate. Coverage includes necessary transportation costs from place of birth to the nearest specialized Participating treatment center. Adopted Children A legally adopted child or a child for whom a Subscriber is a court appointed legal guardian, and who meets the definition of a Covered Dependent, will be treated as a dependent from the date of adoption, or upon the date the child was placed for adoption with the Subscriber, or the date of appointment of a minor for whom guardianship has been granted by court or testamentary appointment. Placed for adoption means the assumption and retention of a legal obligation for total or partial support of a child in anticipation of adoption of the child. The placement must take effect on or after the date the Subscriber's coverage becomes effective and, the Subscriber is requested to make a written request for coverage within 31 days of: i) the date the child is adopted or placed with the Subscriber for adoption or ii) the date of court or testamentary appointment; to continue coverage beyond the initial 31day period only if an additional premium payment is required for the Covered Dependent. Special Rules Which Apply to Children Qualified Medical Child Support Order Coverage is available for a dependent child of an insuring parent eligible for family coverage, if there is a qualified medical child support order requiring the insuring parent to provide dependent health coverage for a child. If the insuring parent is not already covered, Aetna will allow the insuring parent to enroll in family coverage and include the child and will not apply any enrollment period restrictions. The child must meet the definition of a Covered Dependent, and the insuring parent must make a written request for coverage within 31 days of the court order. If the insuring parent does not enroll the child, Aetna will allow the non-insuring parent, child support enforcement agency or Department of Health and Mental Hygiene to enroll the child regardless of the enrollment period restrictions. -13-

14 Handicapped Children Coverage is available for a child who has reached the maximum dependent age for a child under this Certificate and is chiefly dependent upon the Subscriber for support and maintenance and is incapable of self-support due to mental or physical incapacity. The incapacity must have commenced prior to the age the dependent would have lost eligibility. In order to continue coverage for a handicapped child, the Subscriber must provide evidence of the child's incapacity and dependency to Aetna within 31 days of the date the child's coverage would otherwise terminate. Proof of continued incapacity, including a medical examination, must be submitted to Aetna as requested, but not more frequently than annually beginning after the 2 year period following the child's attainment of the maximum dependent age. This eligibility provision will no longer apply on the date the dependent s incapacity ends. Notification of Change in Status It shall be a Member s responsibility to notify Aetna of any changes which affect the Member s coverage under this Certificate, unless a different notification process is agreed to between Aetna and Contract Holder. Such status changes include, but are not limited to, change of address, change of Covered Dependent status, and enrollment in Medicare or any other group health plan of any Member. Additionally, if requested, a Subscriber must provide to Aetna, within 31 days of the date of the request, evidence satisfactory to Aetna that a dependent meets the eligibility requirements described in this Certificate. Special Enrollment Period An eligible individual and eligible dependents may be enrolled during a Special Enrollment Period. A Special Enrollment Period may apply when an eligible individual or eligible dependent loses other health coverage or when an eligible individual acquires a new eligible dependent through marriage, birth, adoption, placement for adoption or placement for foster care. Special Enrollment Period for Certain Individuals Who Lose Other Health Coverage: An eligible individual or an eligible dependent may be enrolled during a Special Enrollment Period, if the following requirements, as applicable, are met: The eligible individual or the eligible dependent was covered under another group health plan or other health insurance coverage when initially eligible for coverage under Aetna; The eligible individual or eligible dependent previously declined coverage under Aetna; and The employer contributions towards the eligible individuals or eligible dependents other coverage have been terminated or the eligible individual or eligible dependent loses coverage under the other group health plan or other health insurance coverage for one of the following reasons: - The other group health coverage is COBRA continuation coverage under another plan, and the COBRA continuation coverage under that other plan has since been exhausted; - The other coverage is a group health plan or other health insurance coverage, and the other coverage has been terminated as a result of loss of eligibility for the coverage; or - The other health insurance coverage is Medicaid or an S-Chip plan and the eligible individual or eligible dependent no longer qualifies for such coverage. -14-

15 Loss of eligibility includes the following: - A loss of coverage as a result of legal separation, divorce or death; - Termination of employment; - Reduction in the number of hours of employment; - Any loss of eligibility after a period that is measured by reference to any of the foregoing; - Termination of health maintenance organization coverage due to Member action- movement outside of the health maintenance organization service area; and also the termination of health coverage including Non- health maintenance organization, due to plan termination. - Plan ceases to offer coverage to a group of similarly situated individuals; - Cessation of a dependent s status as an eligible dependent - Termination of benefit package Loss of eligibility does not include a loss due to failure of the individual or the participant to pay Premiums on a timely basis or due to termination of coverage for cause as referenced in the Termination of Coverage section of this Certificate. Special Enrollment Period for Individuals Who Become Eligible for State Premium Assistance or Who Experience Certain Triggering Events: The eligible individual or eligible dependent becomes eligible for State premium assistance in connection with coverage under Aetna. The eligible individual or eligible dependent experiences a triggering event. A triggering event occurs when you: 1. Lose minimum essential coverage, which includes loss of pregnancy related coverage under section 1902(a)(10)(A)(i)(IV) and (a)(10)(a)(ii)(ix) of the Social Security Act (Medicaid) by you or your dependent and loss of medically needed coverage under section 1902(a)(10)(C) once per calendar year or while you or your dependent are enrolled in any non-calendar year group health plan or individual health insurance, even if you or your dependent had the option to renew such coverage. The date of the loss of coverage is the last day of the plan or policy year. Loss of coverage does not include loss due to failure to pay premium on a timely basis, including COBRA premium prior to expiration of COBRA coverage; or a rescission. 2. Are enrolled in an employer-sponsored health benefit plan that is not qualified coverage in an eligible employer-sponsored plan and are allowed to terminate existing coverage. 3. Lose eligibility for coverage under a Medicaid plan under Title XIX of the Social Security Act or a state child health plan under Title XXI of the Social Security Act. 4. Become eligible for assistance, with respect to coverage under Maryland Health Connection, under a Medicaid plan or state child health plan, including any waiver or demonstration project conducted under or in relation to a Medicaid plan or state child health plan. 5. Are enrolled in another qualified plan in the SHOP Exchange and you demonstrate to the Exchange that the qualified plan substantially violated a material provision of its contract in relation to you. 6. Gain access to new qualified health plans (QHPs) due to a permanent move. 7. Were not enrolled in QHP coverage; were not enrolled in the QHP you selected; or were eligible for but were not receiving advance payments of the premium tax credit or costsharing reductions as a result of misconduct on the part of a non-exchange entity providing enrollment assistance or conducting enrollment activities. -15-

16 To be enrolled in Aetna during a Special Enrollment Period, the eligible individual or eligible dependent must enroll within: 30 days of the first, fifth, sixth and seventh triggering events; 60 days before coverage ends under the second triggering event; 60 days of the third or fourth triggering event; 60 days, beginning on the date of the eligible individual's or eligible dependent's loss of other group health plan or other health insurance coverage; or 60 days, beginning on the date the eligible individual or eligible dependent - Becomes eligible for state premium assistance in connection with coverage under Aetna, or - Is no longer qualified for coverage under Medicaid or S-Chip. The Effective Date of Coverage will be the first day of the first calendar month following the date the completed request for enrollment is received. Special Enrollment Period When a New Eligible Dependent is Acquired: When a new eligible dependent is acquired through marriage, birth, adoption, placement for adoption, placement for foster care or through a child support order or other court order, the new eligible dependent (and, if not otherwise enrolled, the eligible individual and other eligible dependents) may be enrolled during a special enrollment period. The special enrollment period is a period of 60 days, beginning on the date of the marriage, birth, adoption, placement for adoption, placement for foster care or through a child support order or other court order (as the case may be). If a completed request for enrollment is made during that period, the Effective Date of Coverage will be: In the case of marriage, the first day of the first calendar month following the date the completed request for enrollment is received. In the case of a dependent s birth, adoption, placement for adoption, placement for foster care or through a child support order or other court order, the date of such birth, adoption, placement for adoption, placement for foster care or child support order or other court order. The eligible individual or the eligible dependent enrolling during a special enrollment period will not be subject to late enrollment provisions, if any, described in this Certificate. Effective Date of Coverage Coverage shall take effect at 12:01 a.m. on the Member s effective date. Coverage shall continue in effect from month to month subject to payment of Premiums made by the Contract Holder and subject to the Termination section of the Group Agreement, and the Termination of Coverage section of this Certificate. -16-

17 Hospital Confinement on Effective Date of Coverage If a Member is an inpatient in a Hospital on the Effective Date of Coverage, the Member will be covered as of that date. If the Member is covered by another health plan on that date, Aetna will use its coordination of benefits provision to determine which health plan is responsible for the cost of the services. Aetna will not cover any service that is not a Covered Benefit under this Certificate. To be covered, the Member must utilize Participating Providers and is subject to all the terms and conditions of this Certificate. COVERED BENEFITS A Member shall be entitled to the Covered Benefits as specified below, in accordance with the terms and conditions of this Certificate. Unless specifically stated otherwise, in order for benefits to be covered, they must be Medically Necessary. For the purpose of coverage, Aetna may determine whether any benefit provided under the Certificate is Medically Necessary, and Aetna has the option to only authorize coverage for a Covered Benefit performed by a particular Provider. Preventive care, as described below, will be considered Medically Necessary. Important Note: You should review your Schedule of Benefits for the cost sharing that applies to the Covered Benefits in this section. This will help you become familiar with your payment responsibilities. Some Covered Benefits may have visit limits and maximums that apply to the service or supply. You should always review your Certificate and Schedule of Benefits together. ALL SERVICES ARE SUBJECT TO THE EXCLUSIONS AND LIMITATIONS DESCRIBED IN THIS CERTIFICATE. To be Medically Necessary, the service or supply must: Be care or treatment as likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the Member's overall health condition; Be care or services related to diagnosis or treatment of an existing illness or injury, except for Preventive Care Benefits, as determined by Aetna; With respect to diagnostic procedures, be a diagnostic procedure, indicated by the health status of the Member and be as likely to result in information that could affect the course of treatment as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the Member's overall health condition; Include only those services and supplies that cannot be safely and satisfactorily provided at home, in a Physician s or Dental Provider s office, on an outpatient basis, or in any facility other than a Hospital, when used in relation to inpatient Hospital services; and As to diagnosis, care and treatment be no more costly (taking into account all health expenses incurred in connection with the service or supply) than any equally effective service or supply in meeting the above tests. In determining if a service or supply is Medically Necessary, Aetna s Patient Management Medical Director or its Physician or Dentist designee will consider: Information provided on the Member's health status; -17-

18 Reports in peer reviewed medical literature; Reports and guidelines published by nationally recognized health care organizations that include supporting scientific data; Professional standards of safety and effectiveness which are generally recognized in the United States for diagnosis, care or treatment; The opinion of Health Professionals in the generally recognized health specialty involved; The opinion of the attending Physicians or Dental Providers, which have credence but do not overrule contrary opinions; and Any other relevant information brought to Aetna's attention. All Covered Benefits will be covered in accordance with the guidelines determined by Aetna. A Covered Benefit under the Plan includes a service provided by a Participating Provider when the service is obtained in accordance with the terms of the Plan and this Certificate or a Non-Participating Provider upon Referral or preauthorization by a Participating Provider or Aetna when the service is obtained in accordance with the terms of the Plan and this Certificate. If a Member has questions regarding coverage under this Certificate, the Member may call the Member Services toll-free telephone number listed on the Member s identification card. THE MEMBER IS RESPONSIBLE FOR PAYMENT OF THE APPLICABLE COPAYMENTS AND DEDUCTIBLES LISTED ON THE SCHEDULE OF BENEFITS. EXCEPT FOR DIRECT ACCESS SPECIALIST BENEFITS OR IN A MEDICAL EMERGENCY OR URGENT CARE SITUATION AS DESCRIBED IN THIS CERTIFICATE, THE FOLLOWING BENEFITS MUST BE ACCESSED THROUGH THE PCP S OFFICE THAT IS SHOWN ON THE MEMBER S IDENTIFICATION CARD, OR ELSEWHERE UPON PRIOR REFERRAL ISSUED BY THE MEMBER S PCP. 1. Preventive Care and Wellness Benefits Preventive Care 1. The recommendations and guidelines of the: Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; United States Preventive Services Task Force; Health Resources and Services Administration; and American Academy of Pediatrics/Bright Futures Guidelines for Children and Adolescents as referenced throughout this Preventive Care Benefit may be updated periodically. This Plan is subject to updated recommendations or guidelines that are issued by these organizations beginning on the first day of the Plan Year, one year after the recommendation or guideline is issued. 2. If any diagnostic x-rays, lab, or other tests or procedures are ordered, or given, in connection with any of the Preventive Care Benefits described below, those diagnostic x-rays, lab or other tests or procedures will not be covered as Preventive Care Benefits. Those that are Covered Benefits will be subject to the cost-sharing that applies to those specific services under this Plan. -18-

19 3. Refer to the Schedule of Benefits for information about cost-sharing and maximums that apply to Preventive Care benefits. 4. Gender-Specific Preventive Care Benefits -- covered expenses include any recommended Preventive Care benefits described below that are determined by your provider to be medically necessary, regardless of the sex you were assigned at birth, your gender identity, or your recorded gender. 5. To learn what frequency and age limits apply to routine physical exams and routine cancer screenings, contact your physician or contact Member Services by logging on to your Aetna Navigator secure member website at www. aetna.com or at the toll-free number on your ID card. This information can also be found at the website. Routine Physical Exam Benefit Covered Benefits include office visits to a Member's Primary Care Physician (PCP) for routine physical exams, including routine vision and hearing screenings given as part of the routine physical exam. A routine exam is a medical exam given by a PCP for a reason other than to diagnose or treat a suspected or identified illness or injury, and also includes: Evidence-based items that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force. Services as recommended in the American Academy of Pediatrics/Bright Futures/Health Resources and Services Administration guidelines for children and adolescents. Evidence-informed preventive care and screenings as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. These services may include but are not limited to: - Screening and counseling services, such as those on: - Interpersonal and domestic violence; - Sexually transmitted diseases; and - Human Immune Deficiency Virus (HIV) infections. - Screening for gestational diabetes for women. - High risk Human Papillomavirus (HPV) DNA testing for women age 30 and older. X-rays, lab and other tests given in connection with the exam Preventive screening for osteoporosis, subject to any limitations established by current recommendations of the United States Preventive Services Task Force and the Health Resources and Services Administration, as applicable. For covered newborns: - An initial Hospital check up; - Audiology screening. With respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Individuals are also encouraged to complete a health risk assessment. If an individual voluntarily chooses to complete one, Aetna will provide written feedback to the individual who completed a health risk assessment, with recommendations for lowering risks identified in the completed health risk assessment Benefits for the routine physical exam services above may be subject to visit maximums as shown in the Schedule of Benefits. -19-

20 For details on the frequency and age limits that apply to Routine Physical Exam Benefit, Members may contact their Physician or Member Services by logging onto the Aetna Navigator website or calling the toll-free number on the back of the ID card. Preventive Care Immunizations Benefit Covered Benefits include: Immunizations for infectious diseases; and The materials for administration of immunizations; provided by a Member's PCP or a facility. The immunizations must be recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Preventive Care Drugs and Supplements Covered Benefits include preventive care drugs and supplements (including over-the-counter drugs and supplements) obtained at a pharmacy. They are covered when they are: prescribed by a Physician; obtained at a pharmacy; and submitted to a pharmacist for processing. The preventive care drugs and supplements covered under this plan include, but may not be limited to: Aspirin: Benefits are available to adults. Oral Fluoride Supplements: Benefits are available to children whose primary water source is deficient in fluoride. Folic Acid Supplements: Benefits are available to adult females planning to become pregnant or capable of pregnancy. Iron Supplements: Benefits are available to children without symptoms of iron deficiency. Coverage is limited to children who are at increased risk for iron deficiency anemia. Vitamin D Supplements: Benefits are available to adults to promote calcium absorption and bone growth in their bodies Risk Reducing Breast Cancer Prescription Drugs Covered Benefits include Prescription Drugs when prescribed by a Prescriber and the Prescription is submitted to the pharmacist for processing for a woman who is at: Increased risk for breast cancer, and Low risk for adverse medication side effects Coverage of preventive care drugs and supplements will be subject to any sex, age, medical condition, family history, and frequency guidelines in the recommendations of the United States Preventive Services Task Force. Important Note: For details on the guidelines and the current list of covered preventive care drugs and supplements, including risk reducing breast cancer Prescription Drugs, contact your physician or contact Member Services by logging on to your Aetna Navigator secure member secure website a www. Aetna.com or at the toll-free number on your ID card. Refer to the Schedule of Benefits for the cost-sharing and supply limits that apply to these benefits. -20-

21 Well Woman Preventive Visits Benefit Covered Benefits include a routine well woman preventive exam office visit, including Pap smears, provided by a Member's PCP, Physician, obstetrician, or gynecologist in accordance with the recommendations by the Health Resources and Services Administration. A routine well woman preventive exam is a medical exam given by a Physician for a reason other than to diagnose or treat a suspected or identified illness or injury; and Routine preventive care breast cancer genetic counseling and breast cancer (BRCA) gene blood testing. Covered Benefits include charges made by a Physician and lab for the BRCA gene blood test and charges made by a genetic counselor to interpret the test results and evaluate treatment. These benefits will be subject to any age; family history; and frequency guidelines that are: Evidence-based items or services that have in effect a rating of A or B in the recommendations of the United States Preventive Services Task Force; and Evidence-informed items or services provided in the comprehensive guidelines supported by the Health Resources and Services Administration. Benefits for the well woman preventive visit services above are subject to visit maximums as shown in the Schedule of Benefits. Screening and Counseling Services Benefit Covered Benefits include the following services provided by a Member's PCP or Physician, as applicable, in an individual or group setting: Obesity and Healthy Diet Counseling Benefit Covered Benefits include screening and counseling services to aid in weight reduction due to obesity. Coverage includes: Preventive counseling visits and/or risk factor reduction intervention; Nutritional counseling; and Healthy diet counseling visits provided in connection with Hyperlipidemia (high cholesterol) and other known risk factors for cardiovascular and diet-related chronic disease. Misuse of Alcohol and/or Drugs Benefit Covered Benefits include screening and counseling services to aid in the prevention or reduction of the use of an alcohol agent or controlled substance. Coverage includes preventive counseling visits, risk factor reduction intervention and a structured assessment. Use of Tobacco Products Benefit Covered Benefits include screening and counseling services to aid in the cessation of the use of tobacco products. Coverage includes: Preventive counseling visits; Treatment visits; and -21-

22 Class visits; to aid in the cessation of the use of tobacco products. Tobacco product means a substance containing tobacco or nicotine including: Cigarettes; Cigars; Smoking tobacco; Snuff; Smokeless tobacco; and Candy-like products that contain tobacco. Sexually Transmitted Infection Counseling Covered Benefits include the counseling services to help you prevent or reduce sexually transmitted infections. Genetic Risk Counseling for Breast and Ovarian Cancer Covered Benefits include the counseling and evaluation services to help you assess whether or not you are at risk of breast and ovarian cancer. Benefits for the screening and counseling services above are subject to any limitations established by current recommendations of the United States Preventive Services Task Force and the Health Resources and Services Administration, as applicable. Tobacco cessation prescription and over-the-counter drugs Covered Benefits include FDA- approved prescription drugs and over-the-counter (OTC) drugs to help stop the use of tobacco products, when prescribed by a prescriber and the prescription is submitted to the pharmacist for processing. Routine Cancer Screenings Benefit Covered Benefits include, but are not limited to, the following routine cancer screenings: Mammograms; Fecal occult blood tests; Digital rectal exams; Prostate specific antigen (PSA) tests; Sigmoidoscopies; Double contrast barium enema (DCBE); and Colonoscopies (removal of polyps performed during a screening procedure is a Covered Benefit); and Lung cancer screenings. -22-

23 These benefits will be subject to any age, family history and frequency guidelines that are: Evidence-based items or services that have in effect a rating of A or B in the recommendations of the United States Preventive Services Task Force except that the recommendations regarding breast cancer, mammography, and prevention issued in or around November 2009 are not considered to be current; and Evidence-informed items or services provided in the comprehensive guidelines supported by the Health Resources and Services Administration. For details on the frequency and age limits that apply to Routine Cancer Screenings Benefit, Members may contact their Physician or Member Services by logging onto the Aetna Navigator website or calling the toll-free number on the back of the ID card. As to routine gynecological exams performed as part of a routine cancer screening, the Member may go directly to a Participating obstetrician (OB), gynecologist (GYN), obstetrician/gynecologist (OB/GYN) without a Referral from the PCP. See the Direct Access Specialist Benefits section of the Certificate, for a description of this provision. Prenatal Care Benefit Prenatal care will be covered as Preventive Care for services received by a pregnant female in a PCP, Physician's obstetrician s, or gynecologist's office but only to the extent described below. Coverage for prenatal care under this benefit is limited to pregnancy-related Physician office visits including the initial and subsequent history and physical exams of the pregnant woman (maternal weight, blood pressure, fetal heart rate check and fundal height). Important Note: Refer to the: Maternity Care and Related Newborn Care Benefits section of the Certificate; and Prenatal Care Services, Delivery Services and Postpartum Care Services cost-sharing in the Schedule of Benefits; for more information on coverage for services related to maternity care under this Plan. Comprehensive Lactation Support and Counseling Services Benefit Covered Benefits include comprehensive lactation support (assistance and training in breast feeding) and counseling services provided to females during pregnancy or at any time following delivery, for breastfeeding by a certified lactation support provider. Covered Benefits also include the rental or purchase of breast feeding equipment as described below. Lactation support and lactation counseling services are Covered Benefits when provided in either a group or individual setting. Breast Feeding Durable Medical Equipment Covered Benefits includes the rental or purchase of breast feeding Durable Medical Equipment for the purpose of lactation support (pumping and storage of breast milk) as follows. -23-

24 Breast Pumps Covered Benefits include the following: The rental of a hospital-grade electric pump for a newborn child when the newborn child is confined in a Hospital. The purchase of: - An electric breast pump (non-hospital grade). - A manual breast pump. Breast Pump Supplies Coverage is provided for accessories and supplies needed to operate a covered breast pump. A Member is responsible for the entire cost of any additional pieces of the same or similar equipment purchased or rented for personal convenience or mobility. Aetna reserves the right to limit Covered Benefits to the most cost efficient and least restrictive level of service or item which can be safely and effectively provided. The decision to rent or purchase is at the discretion of Aetna. Important Note: If a breast pump service or supply that a Member needs is covered under this Plan but not available from a Participating Provider in the Member's Service Area, the Member's PCP or Physician, as applicable, may refer the Member to a Non-Participating Provider and this Plan will cover such benefits with approval by Aetna. The Member will be reimbursed for the cost of the breast pump service or supply obtained from a Non- Participating Provider. The Member must submit proof of loss to Aetna to receive a claim payment. Refer to the provision entitled "Proof of Loss and Claim Payments" later in this Certificate. For more information contact Member Services by logging onto Aetna Navigator website at www. aetna.com or calling the toll-free number on the back of the ID card for assistance. Family Planning Services - Female Contraceptives Benefit Important Note: For females with reproductive capacity, Covered Benefits include those services and supplies that are provided to a Member to prevent pregnancy. All contraceptive methods, services and supplies covered under this benefit must be approved by the U.S. Food and Drug Administration (FDA). Coverage includes the examination associated with the use of contraceptive drugs or devices, the insertion or removal of contraceptive devices. Coverage includes counseling services on contraceptive methods provided by a PCP, Physician, obstetrician or gynecologist. Such counseling services are Covered Benefits when provided in either a group or individual setting. The following contraceptive methods are Covered Benefits under this benefit: -24-

25 Voluntary Sterilization Covered Benefits include charges billed separately by the provider for female voluntary sterilization procedures and related services and supplies including, but not limited to, tubal ligation and sterilization implants. Important Reminder: Refer to the section Your Pharmacy Benefit later in this Certificate for additional coverage of female contraceptives. 2. Physician and Other Health Professional Care Primary Care Physician Benefit Office visits during office hours. Home visits. After-hours PCP services. PCPs are required to provide or arrange for on-call coverage 24 hours a day, 7 days a week. If a Member becomes sick or is injured after the PCP's regular office hours, the Member should: - call the PCP's office; - identify himself or herself as a Member; and - follow the PCP's or covering Physician s instructions. If the Member's injury or illness is a Medical Emergency, the Member should follow the procedures outlined under the Emergency Care/Urgent Care Benefits section of this Certificate. Hospital visits. Immunizations for infectious disease, but not if solely for your employment or travel. Allergy testing and allergy injections. Charges made by the Physician for supplies, radiological services, x-rays, and tests provided by the Physician. Alternatives to Physicians Office Visits Walk-in Clinic Benefits Covered Benefits include charges made by walk-in clinics for: Unscheduled, non-emergency illnesses and injuries; The administration of certain immunizations administered within the scope of the clinic s license that are covered under the Preventive Care Benefit section of this Certificate; and Individual screening and counseling services to aid you: - In weight reduction due to obesity; - In developing and maintaining a healthy diet; - To stop the use of tobacco products; - In stress management. -25-

26 The stress management counseling sessions will: Help you to identify the life events which cause you stress (the physical and mental strain on your body.); and Teach you techniques and changes in behavior to reduce the stress. Important Note: Not all services are available at all Walk-In Clinics. The types of services offered will vary by the provider and location of the clinic. For a complete description of the screening and counseling services provided on the use of tobacco products, healthy diet and to aid in weight reduction due to obesity, refer to the Preventive Care Benefits section in this Certificate and the Screening and Counseling Services benefit for a description of these services. These services may also be obtained from your PCP. E-Visits and Telemedicine Consultations Covered Benefits include charges made by your PCP for a routine, non-emergency, medical consultation. You must make your E-visit or Telemedicine appointment through an Aetna authorized internet service vendor. You may have to register with that internet service vendor. Information about providers who are signed up with an authorized vendor may be found in the provider Directory or online in DocFind on or by calling the number on your identification card. Specialist Physician Benefit Covered Benefits include outpatient and inpatient services. If a Member requires ongoing care from a Specialist, the Member may receive a standing Referral to such Specialist. If PCP in consultation with an Aetna Medical Director and an appropriate Specialist determines that a standing Referral is warranted, the PCP shall make the Referral to a Specialist. This standing Referral shall be pursuant to a treatment plan approved by the Aetna Medical Director in consultation with the PCP, Specialist and Member. Member may request a second opinion regarding a proposed surgery or course of treatment recommended by Member s PCP or a Specialist. Second opinions must be obtained by a Participating Provider and are subject to precertification. To request a second opinion, Member should contact their PCP for a Referral. Covered Benefits also include E-visits and Telemedicine consultation. Registration with an internet service vendor may be required. Information about Participating Providers who conduct E-visits and Telemedicine consultation may be found in the provider Directory, online in DocFind on or by calling the number on your Member identification card. Important Reminder: For a description of the preventive care benefits covered under this Certificate, refer to the Preventive Care Benefits section in this Certificate. -26-

27 3. Hospital and Other Facility Care Inpatient Hospital Benefit A Member is covered for services only at Participating Hospitals. All services supplies are subject to precertification by Aetna. In the event that the Member elects to remain in the Hospital after the date that the Participating Provider and/or the Aetna Medical Director has determined and advised the Member that the Member no longer meets the criteria for continued inpatient confinement, the Member shall be fully responsible for direct payment to the Hospital Facility for such additional Hospital, Physician and other Provider services, and Aetna shall not be financially responsible for such additional services. Inpatient Hospital cardiac and pulmonary rehabilitation services are covered by Participating Providers upon Referral issued by the Member s PCP and precertification by Aetna. Refer to the Short-Term Cardiac and Pulmonary Rehabilitation Therapy Services benefit for more information. Outpatient Hospital Benefit A Member is covered for outpatient services and supplies only at Participating Hospitals. All services and supplies are subject to precertification by Aetna. Skilled Nursing Facility Benefit A Member is covered for services only at Participating Skilled Nursing Facilities. All services are subject to precertification by Aetna. In the event that the Member elects to remain in the Skilled Nursing Facility after the date that the Participating Provider and/or the Aetna Medical Director has determined and advised the Member that the Member no longer meets the criteria for continued inpatient confinement, the Member shall be fully responsible for direct payment to the Skilled Nursing Facility for such additional Skilled Nursing Facility, Physician and other Provider services, and Aetna shall not be financially responsible for such additional services. Outpatient Surgery Benefit Coverage is provided for outpatient surgical services and supplies in connection with a covered surgical procedure when furnished by a Participating outpatient surgery center. All services and supplies are subject to precertification by Aetna. Home Health Care Benefit The following services are covered for a Homebound Member when provided by a Participating home health care agency. Precertification must be obtained from Aetna by the Member s attending Participating Physician. Home Health Services are covered for the following: An alternative to otherwise Covered Benefits hospital or other facility services. For Members who receive less than 48 hours of inpatient hospitalization following a mastectomy or removal of a testicle or who undergo a mastectomy or removal of a testicle on an outpatient basis: -27-

28 - One home visit scheduled to occur within 24 hours after discharge from the hospital or outpatient hospital or other facility; and - An additional home visit if prescribed by the Member s attending Participating Physician. In order to be covered, services must satisfy the definition of Home Health Services, including that the plan of treatment covering the home health services is established and approved in writing by the Participating Provider. Outpatient home health short-term physical, speech, or occupational therapy is covered when the above home health care criteria are met. Covered Benefits include delivery of services through patient centered medical homes for Members with chronic conditions, serious illnesses or complex health care needs who agree to participate in a patient centered medical home program. Covered Home Health Care benefits do not include charges for infusion therapy. Hospice Benefit Hospice Care services for a terminally ill Member are covered when precertified by Aetna. Services include: Nursing care provided by or under the supervision of a registered professional nurse. Physical or occupational therapy, or speech-language pathology services. Medical social services under the direction of a Physician. Services of a home health aide who has successfully completed a federally approved training program. Homemaker services. Medical supplies (including Prescription Drugs and biological) and the use of medical appliances. Physicians services. Short-term inpatient care (including both respite and procedures necessary for pain control and acute and chronic symptom management) in an inpatient facility meeting such conditions as the Secretary of Health and Human Services determines to be appropriate to provide such care, but such respite care may be provided only on an intermittent, nonroutine, and occasional basis and may not be provided consecutively over longer than five days. Counseling (including dietary and bereavement counseling) with respect to care of the terminally ill individual and adjustment to his death Other home health benefits listed in the Home Health Benefits section of this Certificate. Coverage is not provided for funeral arrangements, pastoral counseling, and financial or legal counseling. Homemaker or caretaker services, and any service not solely related to the care of the Member, including but not limited to, sitter or companion services for the Member or other Members of the family, transportation, house cleaning, and maintenance of the house are not covered

29 4. Emergency Care and Urgent Care Emergency Care/Urgent Care Benefit 1. Emergency Care: A Member is covered for Emergency Services, provided the service is a Covered Benefit, and Aetna's review determines that a Medical Emergency existed at the time medical attention was sought by the Member. The Copayment for an emergency room visit as described on the Schedule of Benefits will not apply in the event that the Member was referred for such visit by the Member s PCP for services that should have been rendered in the PCP s office or if the Member is admitted into the Hospital. The Member will be reimbursed for the cost for Emergency Services rendered by a nonparticipating Provider located either within or outside the Aetna Service Area, for those expenses, less Copayments, which are incurred up to the time the Member is determined by Aetna and the attending Physician to be medically able to travel or to be transported to a Participating Provider. In the event that transportation is Medically Necessary, the Member will be reimbursed for the cost as determined by Aetna, minus any applicable Copayments. Reimbursement may be subject to payment by the Member of all Copayments which would have been required had similar benefits been provided during office hours and upon prior Referral to a Participating Provider. If the Medial Emergency requires emergency surgery, the Member will be reimbursed for the cost of follow-up care provided by a Non-Participating Provider, provided the follow-up care is: Medically Necessary; Directly related to the condition for which the surgical procedure was performed; and Provided in consultation with the Members PCP. Aetna will not impose any cost-sharing requirement for any follow-up care that exceeds what a Member is required to pay for services rendered by a physician, oral surgeon, periodontist, or podiatrist who is a Participating Provider. Medical transportation is covered during a Medical Emergency. -29-

30 2. Urgent Care: Urgent Care within the Aetna Service Area. If the Member needs Urgent Care while within the Aetna Service Area, but the Member s illness, injury or condition is not serious enough to be a Medical Emergency, the Member should first seek care through the Member s PCP. If the Member s PCP is not reasonably available to provide services for the Member, the Member may access Urgent Care from a Participating Urgent Care Facility within the Aetna Service Area. Urgent Care Outside the Aetna Service Area. The Member will be covered for Urgent Care obtained from a Physician or licensed facility outside of the Aetna Service Area if the Member is temporarily absent from the Aetna Service Area and receipt of the health care service cannot be delayed until the Member returns to the Aetna Service Area. A Member is covered for any follow-up care. Follow-up care is any care directly related to the need for Emergency Services which is provided to a Member after the Medical Emergency or Urgent Care situation has terminated. All follow-up and continuing care must be provided or arranged by a Member s PCP. The Member must follow this procedure, or the Member will be responsible for payment for all services received. -30-

31 5. Specific Conditions Maternity Care and Related Newborn Care Benefit Outpatient and inpatient pre-natal and postpartum care and obstetrical services provided by Participating Providers are a Covered Benefit. The Participating Provider is responsible for obtaining any required precertification for all non-routine obstetrical services from Aetna after the first prenatal visit. Coverage does not include routine maternity care (including delivery) received while outside the Service Area unless the Member receives precertification from Aetna. As with any other medical condition, Emergency Services are covered when Medically Necessary. As an exception to the Medically Necessary requirements of this Certificate, the following coverage is provided for a mother and newly born child: A minimum of 48 hours of inpatient care in a Participating Hospital following a vaginal delivery; A minimum of 96 hours of inpatient care in a Participating Hospital following a cesarean section; or A shorter Hospital stay, if requested by a mother, and if determined to be medically appropriate by the Participating Providers in consultation with the mother. If the mother remains in the Hospital for a least the minimum hours above, one home visit will be included. The visit must be prescribed by the Participating Provider and Precertified by Aetna. The visit is not subject to cost sharing. If the mother is discharged earlier, Covered Benefits will include, when precertified by Aetna: One home visit within 24 hours after the Hospital stay; and One additional home visit as prescribed by the Participating Provider. Visits are not subject to cost sharing. A home visit shall: Be provided in accordance with generally accepted standards of nursing practice for home care of a mother and newborn child; Be provided by a registered nurse with at least 1 year of experience in maternal and child health nursing or in community health nursing with an emphasis on maternal and child health; and Include any services required by the attending Participating Provider If the mother remains in the Hospital for medical reasons, the mother may request that the newborn also remain in the Hospital. Covered Benefits will include up to 4 additional Hospital stay days for the newborn, when precertified by Aetna. -31-

32 Reconstructive Breast Surgery Benefit Covered Benefits include reconstruction of the breast on which a mastectomy was performed, including an implant and areolar reconstruction and breast prosthesis. Also included are all stages of surgery on a healthy breast to make it symmetrical with the reconstructed breast and Medically Necessary treatment of the physical complications of all stages of mastectomy, including lymphedema, in a manner determined in consultation with the attending physician and the patient. Reconstructive or Cosmetic Surgery and Supplies Benefit Covered Benefits include charges made by a Physician, Hospital, or surgery center for reconstructive services and supplies, including: Surgery needed to improve a significant functional impairment of a body part. Surgery to correct the result of an accidental injury, including subsequent related or staged surgery. Surgery to correct the result of an injury that occurred during a covered surgical procedure. Mental Disorders Benefit Covered Benefits include services and supplies for the treatment of Mental Disorders by Behavioral Health Providers. Important Reminder Not all types of services are covered. Not covered are: Services by pastoral or marital counselors. Therapy for sexual problems. Treatment for learning disabilities and intellectual disabilities. Telephone therapy. Travel time to the Member s home to conduct therapy. Services rendered or billed by schools, or halfway houses or members of their staff. Marriage counseling. See Exclusions section for more information. Covered Benefits include services and supplies provided by a Hospital, Psychiatric Hospital, Residential Treatment Facility or Behavioral Health Provider for the treatment of Mental Disorders as follows:. Inpatient Hospital, Psychiatric Hospital, or Residential Treatment Facility services include: - Room and board, such as ward, semi-private, or intensive care accommodations. A private room is covered only if Medically Necessary. If the private room is not Medically Necessary, only the Hospital s average charge for semi-private accommodations will be covered. - General nursing care. - Meals and special diets. - Other services and supplies Inpatient benefits are payable only if the severity of your condition requires services that are only available in an inpatient setting. -32-

33 Outpatient treatment received while not confined as an inpatient in a Hospital, Psychiatric Hospital or Residential Treatment Facility, including intensive day treatment programs and Partial Hospitalization Treatment as described below. Hospital emergency room services and supplies. Partial Hospitalization Treatment (more than 4 hours, but less than 24 hours per day of clinical treatment) provided in a facility or program for short-term and intensive treatment provided under the direction of a Physician. The facility or program does not make a room and board charge for the treatment. Partial Hospitalization Treatment will only be covered if: - You would need a higher level of care (for example, inpatient, residential, crisis stabilization) if you were not admitted to this type of facility or program; and - The severity of your condition requires services provided in a Partial Hospitalization Treatment setting. Behavioral Health Provider diagnosis and treatment services, including: - Diagnostic evaluation. - Crisis intervention and stabilization for acute episodes. - Medication evaluation and management (pharmacotherapy). - Treatment and counseling (including individual or group therapy visits. - Intensive outpatient treatment in an office or other professional setting. - Electroconvulsive therapy. - Inpatient services. - Outpatient diagnostic tests provided and billed by a Behavioral Health Provider. - Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility. - Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment. Benefits are covered in the same way as those for any other disease. Important Reminder Inpatient treatments must be precertified by Aetna. Substance Abuse Benefit Covered Benefits include services and supplies for the treatment of Substance Abuse by Behavioral Health Providers and medical addictionologists. Important Note: Not all types of services are covered. For example, telephone therapy, travel time to the Member s home to conduct therapy, and services rendered or billed by schools, or halfway houses or members of their staff. See Exclusions section for more information. Covered Benefits include services and supplies by a Hospital, Psychiatric Hospital, Residential Treatment Facility or Behavioral Health Provider for the treatment of Substance Abuse as follows: Inpatient services include: - Room and board, such as ward, semi-private, or intensive care accommodations. A private room is covered only if Medically Necessary. If the private room is not Medically Necessary, only the Hospital s average charge for semi-private accommodations will be covered. -33-

34 - General nursing care. - Meals and special diets. - Other services and supplies Outpatient treatment received while not confined as an inpatient in a Hospital, Psychiatric Hospital or Residential Treatment Facility, including intensive day treatment programs or as part of Partial Hospitalization Treatment as described below. Hospital emergency room services and supplies. Partial Hospitalization Treatment (more than 4 hours, but less than 24 hours per day of clinical treatment) provided in a facility or program for short-term and intensive treatment provided under the direction of a Physician. The facility or program does not make a room and board charge for the treatment. Partial Hospitalization Treatment will only be covered if: - You would need a higher level of care (for example, inpatient, residential, crisis stabilization) if you were not admitted to this type of facility or program; and - The severity of your condition requires services provided in a Partial Hospitalization Treatment setting. Behavioral Health Provider diagnosis and treatment services, including: - Diagnostic evaluation. - Crisis intervention and stabilization for acute episodes. - Medication evaluation and management (pharmacotherapy). - Treatment and counseling (including individual or group therapy visits. - Diagnosis and treatment of alcoholism and drug abuse, including detoxification, treatment and counseling. - Intensive outpatient treatment in an office or other professional setting. - Electroconvulsive therapy. - Inpatient services. - Outpatient diagnostic tests provided and billed by a Behavioral Health Provider. - Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility. - Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment. Benefits are covered in the same way as those for any other disease. Important Reminder Inpatient treatments must be precertified by Aetna. Diabetes Benefit Covered Benefits include the following services, supplies, equipment, and training for the treatment of insulin- and non-insulin-dependent diabetes and elevated blood glucose levels during pregnancy: Services and Supplies: - Foot care to minimize the risk of infection; - Insulin preparations; - Diabetic needles and syringes; - Injection aids for the blind; - Diabetic test agents; - Lancets/lancing devices; - Prescribed oral medications whose primary purpose is to influence blood sugar; - Alcohol swabs; -34-

35 - Injectable glucagons; and - Glucagon emergency kits. Equipment: - External insulin pumps; and - Blood glucose monitors without special features unless required due to blindness. Training: - Self-management training provided by a licensed health care provider certified in diabetes self-management training. Treatment of Infertility Services Covered Benefits include Infertility services provided to a Member subject to all exclusions and limitations set forth in this Certificate. Morbid Obesity Benefit Covered Benefits include surgical treatment, including related outpatient services, to treat Morbid Obesity that is: Recognized by the National Institutes of Health as effective for the surgical treatment of morbid obesity; and Consistent with guidelines approved by the National Institute of Health. Dental Care Benefit Covered Benefits include general anesthesia and associated Hospital or ambulatory facility services and supplies for dental care for covered individual who are: Age 7 years or younger or developmentally disabled and for whom: - Successful results cannot be expected from dental care provided under local anesthesia because of physical, intellectual, or medically compromising conditions of the covered individual; and - Superior results can be expected from dental care provided under general anesthesia. Age 17 years or younger and who: - Are extremely uncooperative, fearful, or uncommunicative: - Have dental needs of such magnitude that treatment should not be delayed or deferred; and - For lack of treatment can be expected to result in oral pain, infection, loss of teeth, or other increased oral or dental morbidity. Transplant Benefit Once it has been determined that a Member may require a Transplant, the Member or the Member s Physician must call the Aetna precertification department to discuss coordination of the Transplant process. Non-experimental or non-investigational Transplants coordinated by Aetna and performed at an -35-

36 Institute of Excellence, (IOE), are Covered Benefits. The IOE facility must be specifically approved and designated by Aetna to perform the Transplant required by the Member. Covered Benefits include the following when provided by an IOE. Inpatient and outpatient expenses directly related to a Transplant Occurrence. Charges made by a Physician or Transplant team. Compatibility testing of prospective organ donors who are immediate family members. For the purpose of this coverage, an immediate family member is defined as a first-degree biological relative. These are your: biological parent, sibling or child. Charges for activating the donor search process with national registries. Charges made by a Hospital or outpatient facility and/or Physician for the medical and surgical expenses of a live donor, but only to the extent not covered by another plan or program. Related supplies and services provided by the IOE facility during the Transplant Occurrence process. These services and supplies may include: physical, speech and occupational therapy; biomedicals and immunosuppressants; Home Health Services and home infusion services. Any Copayments associated with Transplants are set forth in the Schedule of Benefits. Copayments apply per Transplant Occurrence. One Transplant Occurrence includes the following four phases of Transplant care: Pre-Transplant Evaluation/Screening: Includes all Transplant-related professional and technical components required for assessment, evaluation and acceptance into a Transplant facility s Transplant program. Pre-Transplant/Candidacy Screening: Includes HLA typing of immediate family members. Transplant Event: Includes inpatient and outpatient services for all Transplant-related health services and supplies provided to a Member and donor during the one or more surgical procedures or medical therapies for a Transplant; prescription drugs provided during the Member s inpatient stay or outpatient visit(s), including bio-medical and immunosuppressant drugs; physical, speech or occupational therapy provided during the Member s inpatient stay or outpatient visit(s); cadaveric and live donor organ procurement. Follow-up Care: Includes Home Health Services; home infusion services; and Transplantrelated outpatient services -36-

37 For the purposes of this section, the following will be considered to be one Transplant Occurrence: Heart Lung Heart/ Lung Simultaneous Pancreas Kidney (SPK) Pancreas Kidney Liver Intestine Bone Marrow/Stem Cell Transplant Multiple organs replaced during one Transplant surgery Tandem Transplants (Stem Cell) Sequential Transplants Re-Transplant of same organ type within 180 days of the first Transplant Any other single organ Transplant, unless otherwise excluded under the coverage The following will be considered to be more than one Transplant Occurrence: Autologous Blood/Bone Marrow Transplant followed by Allogenic Blood/Bone Marrow Transplant (when not part of a tandem Transplant) Allogenic Blood/Bone Marrow Transplant followed by an Autologous Blood/Bone Marrow Transplant (when not part of a tandem Transplant) Re-Transplant after 180 days of the first Transplant Pancreas Transplant following a kidney Transplant A Transplant necessitated by an additional organ failure during the original Transplant surgery/process. More than one Transplant when not performed as part of a planned tandem or sequential Transplant, (e.g. a liver Transplant with subsequent heart Transplant). Travel and Lodging Expenses Travel and Lodging Expenses are those expenses incurred by an IOE patient and a companion (two companions if the patient is under age 18) to travel between the IOE patient s home and the IOE facility, if the facility is located 100 miles or more from the IOE patient s home. Travel expenses include those incurred for round trip air, train, or bus travel, but only in coach class. You must be approved by Aetna for this program before you incur the expenses, otherwise you will not be reimbursed. Your approval notification from Aetna will describe the process to follow for reimbursement. You will be required to submit proof of loss (receipts) to Aetna. For details about this program, contact Member Services at the toll-free number on your ID card. -37-

38 6. Specific Therapies and Tests Diagnostic and Preoperative Testing Benefit Diagnostic Complex Imaging Benefit Covered Benefits include outpatient Physician, Hospital or a licensed imaging or radiological facility for complex imaging services to diagnose an illness or injury, including: C.A.T. scans; Magnetic Resonance Imaging (MRI); Nuclear medicine imaging, including Positron Emission Tomography (PET) Scans; and Any other outpatient diagnostic imaging service costing over $500. Complex Imaging Expenses for preoperative testing will be payable under this benefit. Outpatient Diagnostic Lab Work Covered Benefits include lab services, and pathology and other tests provided to diagnose an illness or injury. You must have definite symptoms that start, maintain or change a plan of treatment prescribed by a Physician. The charges must be made by a Physician, Hospital or licensed radiological facility or lab. Important Reminder: Refer to the Schedule of Benefits for details about any cost-sharing that may apply to outpatient diagnostic testing, lab services and radiological services. Outpatient Diagnostic Radiological Services Covered Benefits include radiological services (other than complex imaging services), provided to diagnose an illness or injury. You must have definite symptoms that start, maintain or change a plan of treatment prescribed by a Physician. The services must be provided by a Physician, Hospital or licensed radiological facility. Outpatient Preoperative Testing Prior to a scheduled covered surgery, Covered Benefits include tests performed by a Hospital, Physician or licensed diagnostic laboratory provided the surgery is a Covered Benefit and the tests are: Related to your surgery, and the surgery takes place in a Hospital; Completed within 14 days before your surgery; Performed on an outpatient basis; Covered if you were an inpatient in a Hospital; Not repeated in or by the Hospital where the surgery will be performed. Test results should appear in your medical record kept by the Hospital where the surgery is performed. If your tests indicate that surgery should not be performed because of your physical condition, the plan will cover the tests, however surgery will not be covered. -38-

39 Important Reminder: Complex Imaging testing for preoperative testing is covered under the Diagnostic Complex Imaging Expense section. Separate cost sharing may apply. Refer to your Schedule of Benefits for information on cost sharing amounts for complex imaging. Controlled Clinical Trials Benefit Covered Benefits include patient costs for services and supplies for treatment provided for Members participating in controlled clinical trials. Controlled clinical trials means a treatment that is: Approved by an Institutional Review Board; Conducted for the primary purpose of determining whether or not a particular treatment is safe and efficacious; and Is a study or investigation that is approved or funded by one or more of the following; - The National Institutes of Health; - The Centers for Disease Control and Prevention; - The Agency for Health Care Research and Quality; - The Centers for Medicare & Medicaid Services; - Cooperative group or center of any of the entities described above or the Department of Defense or the Department of Veterans Affairs; - A qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants; - The Food and Drug Administration; - The Department of Energy. Patient cost means the cost of a Medically Necessary health care service incurred for treatment of a Member for purposes of a clinical trial. Patient cost does not include the cost of: An investigational drug or device. Non-health services required as a result of treatment received in a clinical trial. Managing research associated with the clinical trial. Any requirement that a Member must use a Participating Provider will not apply to this Benefit. Services incurred in a controlled clinical trial may be rendered outside the Plan s Service Area. Outpatient Therapies Infusion Therapy Benefit Infusion Therapy is the intravenous or continuous administration of medications or solutions that are Medically Necessary for the Member s course of treatment. The following outpatient Infusion Therapy services and supplies are covered for a Member when provided by a Participating Provider: The pharmaceutical when administered in connection with Infusion Therapy and any medical supplies, equipment and nursing services required to support the Infusion Therapy; -39-

40 Professional services; Total parenteral nutrition (TPN); Chemotherapy; Drug therapy (includes antibiotic and antivirals); Pain management (narcotics); and Hydration therapy (includes fluids, electrolytes and other additives). Not included under this infusion therapy benefit are charges incurred for: Enteral nutrition; Blood transfusions and blood products; Dialysis; and Insulin. Benefits payable for Infusion Therapy will not count toward any applicable Home Health Care maximums. Chemotherapy Benefit Covered Benefits include chemotherapy treatment. Coverage levels depend on where treatment is received. In most cases, chemotherapy is covered as outpatient care. Inpatient Hospitalization for chemotherapy is limited to the initial dose while Hospitalized for the diagnosis of cancer and when a Hospital stay is otherwise Medically Necessary based on your health status. Radiation Therapy Benefit Covered Benefits include the treatment of illness by x-ray, gamma ray, accelerated particles, mesons, neutrons, radium or radioactive isotopes. Short Term Cardiac and Pulmonary Rehabilitation Therapies Services Benefit The following benefits are covered when rendered by Participating Providers upon Referral issued by the Member s PCP and precertified by Aetna. Cardiac rehabilitation benefits are available to individuals who have been diagnosed with significant cardiac disease, or who have suffered a myocardial infarction, or have undergone invasive cardiac treatment immediately preceding referral for cardiac rehabilitation. Cardiac rehabilitation is a comprehensive program involving medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counseling. Benefits include continuous EKG telemetric monitoring during exercise, EKG rhythm strip with interpretation, physician s revision of exercise prescription, and follow up, examination for physician to adjust medication or change regimen. Pulmonary rehabilitation benefits are available as part of a Member s inpatient Hospital stay. A course of outpatient pulmonary rehabilitation appropriate for your condition is covered when Medically Necessary for the treatment of reversible pulmonary disease states. -40-

41 Short-Term Rehabilitation and Habilitation Therapy Services Benefit Covered Benefits include short-term rehabilitation and habilitation therapy services, as described below, when prescribed by a Physician up to the benefit maximums listed on your Schedule of Benefits. The services have to be performed by: A licensed or certified physical, occupational or speech therapist; A Hospital, Skilled Nursing Facility, or Hospice Facility; A Home Health Care Agency; or A Physician. Cognitive Therapy, Physical Therapy, Occupational Therapy, Speech Therapy Rehabilitation and Habilitation Benefits Coverage is subject to the limits, if any, shown on the Schedule of Benefits. For inpatient rehabilitation and habilitation benefits for the services listed below, refer to the Inpatient Hospital and Skilled Nursing Facility benefits provision under the Covered Benefits section of this Certificate. Physical therapy is covered provided the therapy is expected to: - Significantly improve, develop or restore physical functions; or - Improves any impaired function as a result of an acute illness, injury or surgical procedure. Physical therapy does not include educational training. Occupational therapy, (except for vocational rehabilitation or employment counseling), is covered provided the therapy is expected to: - Significantly improve, develop or restore physical functions; or - Improve an impaired function as a result of an acute illness, injury or surgical procedure; or - To relearn skills to significantly improve independence in the activities of daily living. Occupational therapy does not include educational training. Speech therapy is covered provided the therapy is expected to: - Restore the speech function or correct a speech impairment resulting from illness or injury or; - Improve delays in speech function development as a result of a congenital or genetic birth defect. Speech function is the ability to express thoughts, speak words and form sentences. Speech impairment is difficulty with expressing one s thoughts with spoken words. Cognitive therapy associated with physical rehabilitation or habilitation is covered when the cognitive deficits have been acquired as a result of neurologic impairment due to trauma, stroke, or encephalopathy, and when the therapy is coordinated with Aetna as part of a treatment plan intended to restore previous cognitive function. -41-

42 Covered habilitative services are health care services and devices that include occupational therapy, physical therapy and speech therapy, and services for cleft lip and cleft palate and orthodontic, oral surgery, otologic and audiological services that help a person keep, learn or improve skills and functioning for daily living. Benefits are not available for habilitative services provided in early intervention and school services. Chiropractic Treatment Services by a Participating Provider when Medically Necessary and upon prior Referral issued by the PCP are covered. Services must be consistent with Aetna guidelines for spinal manipulation to correct a muscular skeletal problem or subluxation which could be documented by diagnostic x-rays performed by an Aetna Participating radiologist. -42-

43 7. Other Covered Benefits Acupuncture Benefit The plan covers acupuncture services provided by a health professional. Ambulance Service Benefit Covered Benefits includes professional Ambulance services, as follows: Ground Ambulance Covered Benefits include transportation: To the first Hospital where treatment is given in a medical emergency. From one Hospital to another Hospital in a medical emergency when the first Hospital does not have the required services or facilities to treat your condition. From Hospital to home or to another facility when other means of transportation would be considered unsafe due to your medical condition. From home to Hospital for covered inpatient or outpatient treatment when other means of transportation would be considered unsafe due to your medical condition. When during a covered inpatient stay at a Hospital, Skilled Nursing Facility or acute rehabilitation Hospital, an Ambulance is required to safely and adequately transport you to or from inpatient or outpatient Medically Necessary treatment. Air or Water Ambulance Covered Benefits include transportation to a Hospital by air or water Ambulance when: Your condition is unstable, and requires medical supervision and rapid transport; and In a medical emergency, transportation from one Hospital to another Hospital; when the first Hospital does not have the required services or facilities to treat your condition and you need to be transported to another Hospital; and the two conditions above are met. Blood and Blood Services Benefits Covered Benefits include all cost recovery expenses for blood, blood products, derivatives, components, biologics, and serums to include autologous services, whole blood, red blood cells, platelets, plasma, immunoglobulin, and albumin. -43-

44 Durable Medical Equipment (DME) Benefit Durable Medical Equipment will be provided when precertified by Aetna. Durable Medical Equipment includes but is not limited to nebulizers, peak flow meters, prosthetic devices such as leg, arm, back, or neck braces, artificial legs, arms, or eyes, and the training necessary to use these prosthetics. The wide variety of Durable Medical Equipment and continuing development of patient care equipment makes it impractical to provide a complete listing, therefore, the Aetna Medical Director has the authority to approve requests on a case-by-case basis. Covered Durable Medical Equipment includes those items covered by Medicare unless excluded in the Exclusions and Limitations section of this Certificate. Aetna reserves the right to provide the most cost efficient and least restrictive level of service or item which can be safely and effectively provided. The decision to rent or purchase is at the discretion of Aetna. Instruction and appropriate services required for the Member to properly use the item, such as attachment or insertion, is also covered upon precertification by Aetna. Replacement, repairs and maintenance are covered only if it is demonstrated to the Aetna that: It is needed due to a change in the Member s physical condition; or It is likely to cost less to buy a replacement than to repair the existing equipment or to rent like equipment. All maintenance and repairs that result from a misuse or abuse are a Member s responsibility. Family Planning Services - Other Covered Benefits include the following family planning services, even though not provided to treat an illness or injury: Voluntary termination of pregnancy; and Voluntary sterilization for males. Important Notes: Refer to the Schedule of Benefits for details about cost sharing that apply to Family Planning Services - Other. For more information, see the sections on Family Planning Services - Female Contraceptives, Pregnancy Expenses and Treatment of Infertility in this Certificate. Hearing Aid Benefit Covered Benefits for hearing care includes hearing exams, prescribed hearing aids and hearing aid expenses as described below. Hearing aid means: Any wearable, non-disposable instrument or device designed to aid or compensate for impaired human hearing; and Parts, attachments or accessories. -44-

45 Covered Benefits include the following: An audiometric hearing exam and evaluation for a hearing aid prescription performed by: - A Physician certified as an otolaryngologist or otologist; or - An audiologist who (1) is legally qualified in audiology; or (2) holds a certificate of Clinical Competence in Audiology from the American Speech and Hearing Association in the absence of any licensing requirements; and who performs the exam at the written direction of a legally qualified otolaryngologist or otologist. Electronic hearing aids, installed in accordance with a Prescription written during a covered hearing exam; Any other related services necessary to access, select and adjust or fit a hearing aid. Covered Benefits for hearing aids will not include per 36 consecutive month period more than one hearing aid per ear. Hearing Aids Alternate Treatment Rule Sometimes there are several types of hearing aids that can be used to treat a medical condition, all of which provide acceptable results. When alternate hearing aids can be used, the plan s coverage may be limited to the cost of the least expensive device that is: Customarily used nationwide for treatment, and Deemed by the medical profession to be appropriate for treatment of the condition in question. The device must meet broadly accepted standards of medical practice, taking into account your physical condition. You should review the differences in the cost of alternate treatment with your Physician. Of course, you and your Physician can still choose the more costly treatment method. You are responsible for any charges in excess of what the plan will cover. This Alternate Treatment Rule provision will not operate to deny benefits as mandated by any applicable state statute or regulation. Jaw Joint Disorder Treatment Covered Benefits include care by a Physician, Hospital or surgery center for the diagnosis and surgical treatment of jaw joint disorder. A jaw joint disorder is defined as a painful condition: Of the jaw joint itself, such as temporomandibular joint dysfunction (TMJ) syndrome; or Involving the relationship between the jaw joint and related muscles and nerves such as myofacial pain dysfunction (MPD). Unless specified above, not covered under this benefit are charges for non-surgical treatment of a Jaw Joint Disorder. Nutritional Services Benefit Covered Benefits include nutritional services for the treatment of cardiovascular disease, diabetes, malnutrition, cancer, cerebral vascular disease, or kidney disease. Nutritional services include benefits for Medically Necessary nutritional counseling by a licensed dietician-nutritionist, Physician, physician assistant, or nurse practitioner for a Member at risk due to nutritional history, current dietary intake, medication use or chronic illness or condition. Services also include nutritional therapy by a licensed dietician-nutritionist, working in a Member s PCP, to treat a chronic illness or condition. -45-

46 Nutritional Supplements Benefit Covered Benefits include nutritional supplements (formulas) as needed for the therapeutic treatment of phenylketonuria, branched-chain ketonuria, galactosemia and homocystinuria as administered under the direction of a Physician and medical food for persons with metabolic disorders when ordered by a health care practitioner qualified to provide diagnosis and treatment in the field of metabolic disorders. Prosthetic Appliances Benefit The Member s initial provision and replacement of a prosthetic device that temporarily or permanently replaces all or part of an external body part lost or impaired as a result of disease or injury or congenital defects is covered, when such device is prescribed by a Participating Provider, administered through a Participating or designated prosthetic Provider and precertified by Aetna. Coverage includes repair and replacement when due to growth and development or a significant change in a Member s physical condition.. Repair and replacement due to loss, misuse, abuse or theft are not covered. Instruction and appropriate services required for the Member to properly use the item (such as attachment or insertion) are covered. Aetna reserves the right to provide the most cost efficient and least restrictive level of service or item which can be safely and effectively provided. Vision Care Benefits Pediatric Routine Vision Exams Covered Benefits include services by a legally qualified ophthalmologist or optometrist for a routine vision exam. The exam will include refraction, dilation, if professionally indicated, and glaucoma testing. This benefit is subject to an age limit as shown on the Schedule of Benefits. Pediatric Vision Care Services and Supplies Covered Benefits include charges for the following vision care services and supplies: Office visits to an ophthalmologist, optometrist or optician related to fitting of Prescription contact lenses. Preferred eyeglass frames, Prescription lenses or Prescription contact lenses. Non-Preferred eyeglass frames, Prescription lenses or Prescription contact lenses. Coverage includes: Non-conventional Prescription contact lenses that are required to correct visual acuity to 20/40 or better in the better eye and that correction cannot be obtained with conventional lenses. Aphakic Prescription lenses prescribed after cataract surgery has been performed. Low vision services, including prescribed optical devices, such as high powered spectacles, magnifiers and telescopes. This benefit is subject to an age limit as shown on the Schedule of Benefits. A listing of the locations of the vision Participating Providers under this Plan can be accessed at the website. Be sure to look at the appropriate vision Participating Provider listing that applies to your plan, since different Aetna plans use different networks of providers. You must present your ID card to the vision Participating Provider at the time of service. -46-

47 This benefit is subject to the maximums shown on the Schedule of Benefits. As to coverage for Prescription lenses in a Plan Year, this benefit will cover either Prescription lenses for eyeglass frames or Prescription contact lenses, but not both. Adult Routine Vision Exams Covered Benefits include services by a legally qualified ophthalmologist or optometrist for a routine vision exam. The exam will include refraction and glaucoma testing Patient Centered Medical Homes Covered Benefits include services through patient centered medical homes for Members with chronic conditions, serious illness or complex health care needs who agree to participate in a patient centered medical home program. Included are costs from coordination of care, such as: Liaison services between the Member and the health care provider, nurse coordinator, and the case coordination team. Creation and supervision of a care plan. Education of the Member and family regarding the Member s disease, treatment compliance and self-care techniques. Assistance with coordination of care, including arranging consultation with specialist and obtaining Medically Necessary services and supplies, including community resources. Case Management Program Covered Benefits include any other services approved by Aetna s case management program -47-

48 Pediatric Dental Services Covered Benefits include dental services listed in the Pediatric Dental Care Schedule below by a Participating Dental Provider and provided to covered persons through the end of the month in which they turn 19. The plan does not cover all dental care expenses that you incur. Important Reminder: Your dental services and supplies must meet the following rules to be covered by the plan: The services and supplies must be Medically Necessary. The services and supplies must be covered by the plan. Your covered dependent receives services and supplies while covered under the plan or while covered under the Coverage for Dental Work Completed After Termination of Coverage provision. About the Dental Plan The plan is a Dental Plan that covers a limited range of dental services and supplies. You can visit the Participating Dental Provider of your choice when you need dental care. You can choose a Participating Dental Provider who is in the dental network. The Choice Is Yours You have a choice each time you need dental care: Using Participating Providers Participating Dental Providers have agreed to accept the Negotiated Charge. You will be reimbursed for a covered benefit received from a Participating Dental Provider, up to the Negotiated Charge and the maximum benefits under this plan, less any cost sharing required by you. Your Copayment is based on the Negotiated Charge. You will not have to pay any balance bills above the Negotiated Charge for that covered service or supply. You will not have to submit dental claims for treatment received from Participating Dental Providers. Your Participating Dental Provider will take care of claim submission. Aetna will directly pay the Participating Dental Provider less any cost sharing required by you. You will be responsible for any cost share, if any. You will receive notification of what the plan has paid toward your Covered Benefits. It will indicate any amounts you owe towards any cost share or other non-covered Benefits you have incurred. You may elect to receive this notification by , or through the mail. Contact Member Services by logging onto the Aetna website or calling the toll-free number on the back of your ID card if you have questions regarding your statement. -48-

49 Availability of Providers Aetna cannot guarantee the availability or continued participation of a particular Provider. Either Aetna or any Participating Dental Provider may terminate the Provider contract or a Participating Dental Provider may limit the number of patients accepted in a practice. Pediatric Dental Care Schedule If: A charge is made for an unlisted service given for the dental care of a specific condition; and The list includes one or more services that, under standard practices, are separately suitable for the dental care of that condition; then the charge will be considered to have been made for a service in the list that Aetna determines would have produced a professionally acceptable result. The Pediatric Dental Care Schedule is a list of dental benefits that are covered by the plan. There are several categories of Covered Benefits: Diagnostic and Preventive Care Basic Restorative Care Major Restorative Care Orthodontic Treatment These covered services and supplies are grouped as Type A, Type B, Type C, and Orthodontic Treatment. Coverage is also provided for a Dental Emergency. For additional information, please refer later in this amendment to the In Case of a Dental Emergency section. Getting an Advance Claim Review The purpose of the advance claim review is to determine, in advance, the benefits the plan will pay for proposed services. Knowing ahead of time which services are covered by the plan, and the benefit amount payable, helps you and your Participating Dentist make informed decisions about the care you are considering. Important Note: The pre-treatment review process is not a guarantee of benefit payment, but rather an estimate of the amount or scope of benefits to be paid. When to Get an Advance Claim Review An advance claim review is recommended whenever a course of dental treatment is likely to cost more than $300. Ask your Participating Dentist to write down a full description of the treatment you need, using either an Aetna claim form or an ADA approved claim form. Then, before actually treating you, your Participating Dentist should send the form to Aetna. Aetna may request supporting images and other diagnostic records. Once all of the information has been gathered, Aetna will review the proposed treatment plan and provide you and your Participating Dentist with a statement outlining the benefits payable by the plan. You and your Participating Dentist can then decide how to proceed. -49-

50 The advance claim review is voluntary. It is a service that provides you with information that you and your Participating Dentist can consider when deciding on a course of treatment. It is not necessary for emergency treatment or routine care such as cleaning teeth or check-ups. In determining the amount of benefits payable, Aetna will take into account alternate procedures, services, or courses of treatment for the dental condition in question in order to accomplish the anticipated result. (See the Alternate Treatment Rule later in this amendment for more information on alternate dental procedures.) What Is a Course of Dental Treatment? A course of dental treatment is a planned program of one or more services or supplies. The services or supplies are provided by one or more Participating Dentists to treat a dental condition that was diagnosed by the attending Participating Dentist as a result of an oral examination. A course of treatment starts on the date your Participating Dentist first renders a service to correct or treat the diagnosed dental condition. In Case of a Dental Emergency If you need dental care for the palliative treatment (e.g., pain relieving, stabilizing) of a Dental Emergency, you are covered 24 hours a day, 7 days a week. A Dental Emergency is any dental condition which: Occurs unexpectedly; Requires immediate diagnosis and treatment in order to stabilize the condition; and Is characterized by symptoms such as severe pain and bleeding. You must follow the guidelines below when you believe that you have a Dental Emergency. Services provided for a Dental Emergency will be covered at the network level of benefits even if services and supplies are not provided by a Participating Dental Provider. If you have a Dental Emergency, call the Participating Dental Provider. If you cannot reach the Participating Dental Provider or you are away from home, you may get treatment from any Dentist. You should call Member Services for help in finding a Dentist. The care must be for the temporary relief of the Dental Emergency until you can be seen by your Participating Dental Provider. The plan pays a benefit up to the dental emergency maximum. Rules and Limits That Apply to the Dental Benefits Several rules apply to the dental benefits. Following these rules will help you use the plan to your advantage by avoiding expenses that are not covered by the plan. -50-

51 Orthodontic Treatment Rule Orthodontic treatment is covered when it is medically necessary for a covered person with a severe, dysfunctional, handicapping condition such as: Cleft lip and palate, cleft palate, or cleft lip with alveolar process involvement The following craniofacial anomalies: - Hemifacial microsomia; - Craniosynostosis syndromes; - Cleidocranial dental dysplasia; - Arthrogryposis; or - Marfan syndrome Anomalies of facial bones and/or oral structures Facial trauma resulting in functional difficulties Reimbursable orthodontic services include: Pre-orthodontic treatment visit Comprehensive orthodontic treatment Orthodontic retention (removal of appliances, construction and placement of retainers(s) This benefit does not cover charges for the following: Maxillofacial surgery; Myofunctional therapy; Lingually placed direct bonded appliances and arch wires (i.e. invisible braces ); or Removable acrylic aligners (i.e. invisible aligners ). Replacement Rule Crowns, inlays, onlays and veneers, complete dentures, removable partial dentures, fixed partial dentures (bridges) and other prosthetic services are subject to the plan's replacement rule. That means certain replacements of, or additions to, existing crowns, inlays, onlays, veneers, dentures or bridges are covered only when you give proof to Aetna that: You had a tooth (or teeth) extracted after the existing denture or bridge was installed. As a result, you need to replace or add teeth to your denture or bridge. The present crown, inlay and onlay, veneer, complete denture, removable partial denture, fixed partial denture (bridge), or other prosthetic service was installed at least 5 years before its replacement and cannot be made serviceable. Alternate Treatment Rule Sometimes there are several ways to treat a dental problem, all of which provide acceptable results. When alternate services or supplies can be used, the plan's coverage will be limited to the cost of the least expensive service or supply that is: Customarily used nationwide for treatment; and Deemed by the dental profession to be appropriate for treatment of the condition in question. The service or supply must meet broadly accepted standards of dental practice, taking into account your current oral condition. -51-

52 You should review the differences in the cost of alternate treatment with your Participating Dental Provider. Of course, you and your Participating Dental Provider can still choose the more costly treatment method. You are responsible for any charges in excess of what the plan will cover. Coverage for Dental Work Completed After Termination of Coverage Your dental coverage may end while you or your covered dependent is in the middle of treatment. The plan does not cover dental services that are given after your coverage terminates. There is an exception. The plan will cover a course of treatment that began while you were covered by the plan and requires two or more visits on separate days to a dentist's office. Coverage will be continued for up to 90 days after your coverage ends. The plan will cover orthodontics for 60 days after the date coverage terminates if the orthodontist has agreed to or is receiving monthly payments; or until the later of 60 days after the date coverage terminates or the end of the quarter in progress, if the orthodontist has agreed to accept or is receiving payments on a quarterly basis. Jaw Joint Disorder Treatment Rule Coverage for Jaw Joint Disorder treatment is covered as a Type C Service. This includes treatments which alter the jaw, jaw joints, or bite relationships. The following are covered: Diagnosis; Applicable therapy; and Other non-surgical treatment. Pediatric Dental Plan Exclusions Not every dental care service or supply is covered by the plan, even if prescribed, recommended, or approved by your Physician or Dental Provider. The plan covers only those services and supplies that are Medically Necessary. Charges made for the following are not covered except to the extent listed under the Covered Benefits section of the Certificate or by amendment attached to the Certificate. In addition, some services are specifically limited or excluded. This section describes services and supplies that are not covered or subject to special limitations. These dental exclusions are in addition to the exclusions that apply to health coverage. Acupuncture, acupressure and acupuncture therapy, except as provided in the Covered Benefits section of the Certificate. Any charges in excess of the benefit, dollar, day, visit, or supply limits stated in the Certificate. Charges submitted for services: - By an unlicensed Hospital, Physician or other provider; or - By a licensed Hospital, Physician or other provider that are not within the scope of the provider s license. Charges submitted for services that are not rendered, or rendered to a person not eligible for coverage under the plan. -52-

53 Cosmetic services and supplies including plastic surgery, reconstructive surgery, Cosmetic surgery, personalization or characterization of dentures or other services and supplies which improve alter or enhance appearance, and other substances to protect, clean, whiten bleach or alter the appearance of teeth; whether or not for psychological or emotional reasons; except to the extent coverage is specifically provided in the Pediatric Dental Services section of the Certificate. Facings on molar crowns and pontics will always be considered Cosmetic. Crown, inlays and onlays, and veneers except as specifically provided in the Pediatric Dental Services section of the Certificate. Dental Examinations that are: - Solely required by a third party, including examinations and treatments required to obtain or maintain employment, or which an employer is required to provide under a labor agreement; - Solely required by any law of a government, securing insurance or school admissions, or professional or other licenses; - Solely required to travel, attend a school, camp, or sporting event or participate in a sport or other recreational activity; and - Any special medical reports not directly related to treatment except when provided as part of a covered service. Dental implants, removal of implants, braces and other devices to protect, replace, or reposition teeth, unless deemed medically necessary. This exclusion does not apply to medically necessary orthodontia, tooth reimplantation, and tooth transplantation. Dental services and supplies that are covered in whole or in part under any other part of this plan. Experimental or Investigational drugs, devices, treatments or procedures, except as described in the Covered Benefits section of the Certificate. General anesthesia and intravenous sedation, unless specifically covered and only when done in connection with another Medically Necessary covered service or supply. Medicare: Payment for that portion of the charge for which Medicare is the primary payer. Miscellaneous charges for services or supplies including: - Annual or other charges to be in a Physician s practice; - Charges to have preferred access to a Physician s services such as boutique or concierge Physician practices; - Cancelled or missed appointment charges or charges to complete claim forms; Charges the recipient has no legal obligation to pay; or the charges would not be made if the recipient did not have coverage. Non-Medically Necessary services, including but not limited to, those treatments, services, Prescription Drugs and supplies which are not Medically Necessary, as determined by Aetna, for the diagnosis and treatment of illness, injury, restoration of physiological functions, or covered preventive services. Orthodontic treatment except as covered in Pediatric Dental Services section of the Certificate. -53-

54 Prescribed drugs; pre-medication; or analgesia except as provided in the Outpatient Prescription Drug section of the Certificate. Replacement of a device or appliance that have been damaged due to abuse, misuse or neglect and for an extra set of dentures. Replacement of teeth beyond the normal complement of 32. Routine dental exams and other preventive services and supplies, except as specifically provided in the Pediatric Dental Services section of the Certificate. Services and supplies done where there is no evidence of pathology, dysfunction, or disease other than covered preventive services. Services and supplies provided for your personal comfort or convenience, or the convenience of any other person, including a provider. Services and supplies provided in connection with treatment or care that is not covered under the plan. Services rendered before the effective date or after the termination of coverage except as provided in Coverage for Dental Work Completed After Termination of Coverage provision. Space maintainers except when needed to preserve space resulting from the premature loss of deciduous teeth. Surgical removal of impacted wisdom teeth only for orthodontic reasons. Treatment by other than a Dentist or Provider for a service that is not within the lawful scope of practice of a healthcare provider licensed under the Health Occupations Article. The plan will cover some services provided by a licensed dental hygienist under the supervision and guidance of a Dentist. Work related: Any illness or injury related to employment or self-employment including any injuries that arise out of (or in the course of) any work for pay or profit, unless no other source of coverage or reimbursement is available to you for the services or supplies. Sources of coverage or reimbursement may include your employer, workers compensation, or an occupational illness or similar program under local, state or federal law. A source of coverage or reimbursement will be considered available to you even if you waived your right to payment from that source. If you are also covered under a workers compensation law or similar law, and submit proof that you are not covered for a particular illness or injury under such law, that illness or injury will be considered non-occupational regardless of cause

55 EXCLUSIONS AND LIMITATIONS Medical Exclusions The following are not Covered Benefits except as described in the Covered Benefits section of this Certificate or by amendment(s) attached to this Certificate: Services that are not Medically Necessary. Services performed or prescribed under the direction of a person who is not a Health Professional. Services that are beyond the scope of practice of the Health Professional performing the service. Services to the extent they are covered by any government unit, except for veterans in Veterans Administration or armed forces facility for services received for which the recipient is liable. Services for which a Member is not legally, or as a customary practice, required to pay in the absence of a health benefit plan; The purchase, examination, or fitting of eye glasses or contact lenses, except for aphakic patients and soft or rigid gas permeable lenses or sclera shells intended for use in the treatment of a disease or injury. This does not apply to Pediatric Vision Care under Covered Benefits. Personal Care Services and domiciliary care services not stated herein; Services rendered by a Health Professional who is a Member's spouse, mother, father, daughter, son, brother, or sister; Experimental or Investigational Procedures; Practitioner, Hospital, or clinical Services related to radial keratotomy, myopic keratomileusis, and surgery which involves corneal tissue for the purpose of altering, modifying, or correcting myopia, hyperopia, or stigmatic error; In vitro fertilization, ovum transplants and gamete intrafallopian tube transfer, zygote intrafallopian transfer, or cryogenic or other preservation techniques used in these or similar procedures; Services to reverse a voluntary sterilization procedure; Services for sterilization or reverse sterilization for a dependent minor. This does not apply to sterilization procedures for women with reproductive capacity; Medical or surgical treatment for obesity, unless otherwise specified in the Covered Benefit; Medical or surgical treatment or regimen for reducing or controlling weight, unless otherwise specified in the Covered Benefit; Services incurred before the Effective Date of Coverage for a Member; -55-

56 Services incurred after a Member's termination of coverage, including any extension of benefits; Surgery or related services for cosmetic purposes to improve appearance, but not to restore bodily function or correct deformity resulting from disease, trauma, or congenital or developmental anomalies; Services for injuries or diseases related to a Member's job to the extent the Member is required to be covered by a worker's compensation law; Services rendered from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, or similar persons or groups; Personal hygiene and convenience items, including, but not limited to, air conditioners, humidifiers, or physical fitness equipment; Charges for telephone consultations, failure to keep a scheduled visit, or completion of any form; Inpatient admissions primarily for diagnostic studies, unless authorized by Aetna; The purchase, examination, or fitting of hearing aids and supplies, and tinnitus maskers. This does not apply to Hearing Aid Benefits under Covered Benefits. Except for covered ambulance services and Travel Expenses in Transplant Benefit under Covered Benefits, travel, whether or not recommended by a Health Professional; Except for Emergency Services, services received while the Member is outside the United States; Immunizations related to foreign travel; Unless otherwise specified in Covered Benefit, dental work or treatment which includes Hospital or Health Professional care in connection with: - The operation or treatment for the fitting or wearing of dentures, - Orthodontic care or malocclusion, and - Operations on or for treatment of or to the teeth or supporting tissues of the teeth, except for removal of tumors and cysts or treatment of injury to natural teeth due to an ac cident and the treatment is received within 6 months of the accident; Accidents occurring while and as a result of chewing. This does not apply to Dental Benefits under Covered Benefits. Routine foot care, including the paring or removing of corns and calluses, or trimming of nails, unless these services are determined to be Medically Necessary; Arch support, orthotic devices, in-shoe supports, orthopedic shoes, elastic supports, or exams for their prescription or fitting, unless these services are determined to be Medically Necessary; Inpatient admissions primarily for physical therapy, unless authorized by Aetna; Treatment of sexual dysfunction not related to organic disease; -56-

57 Services that duplicate benefits provided under federal, state, or local laws, regulations, or programs; Nonhuman organs and their implantation; Nonreplacement fees for blood and blood products; Lifestyle improvements, including nutrition counseling, or physical fitness programs, unless included as a Covered Benefit; Wigs or cranial prosthesis, unless included as a Covered Benefit; Weekend admission charges, except for emergencies and maternity, unless authorized by Aetna; Out-patient orthomolecular therapy, including nutrients, vitamins, and food supplements, unless included as a Covered Benefit; Temporomandibular joint syndrome (TMJ) treatment and treatment for craniomandibular pain syndrome (CPS), except for surgical services for TMJ and CPS, if Medically Necessary and if there is a clearly demonstrable radiographic evidence of joint abnormality due to disease or injury; Services resulting from accidental bodily injuries arising out of a motor vehicle accident to the extend the services are payable under a medical expense payment provision of an automobile insurance policy; Services for conditions that state or local laws, regulations, ordinances, or similar provisions require to be provided in a public institution; Services for, or related to, the removal of an organ from a Member for purposes of transplantation into another person, unless the: - Transplant recipient is covered under the plan and is undergoing a covered transplant, and - Services are not payable by another carrier; Physical examinations required for obtaining or continuing employment, insurance, or government licensing; Nonmedical ancillary services such as vocational rehabilitation, employment counseling, or educational therapy; Private Hospital room, unless authorized by Aetna; Private duty nursing, unless authorized by Aetna; -57-

58 Limitations In the event there are 2 or more alternative Medical Services which in the sole judgment of Aetna are equivalent in quality of care, Aetna reserves the right to provide coverage only for the least costly Medical Service, as determined by Aetna, provided that Aetna pre-authorizes the Medical Service or treatment. Determinations regarding eligibility for benefits, coverage for services, benefit denials and all other terms of this Certificate are at the sole discretion of Aetna, subject to the terms of this Certificate. 8. Outpatient Prescription Drugs How the Pharmacy Plan Works It is important that you have the information and useful resources to help you get the most out of your Aetna Prescription Drug plan. This Certificate explains: How to access Network Pharmacies and procedures you need to follow; What Prescription Drug expenses are covered and what limits may apply; What Prescription Drug expenses are not covered by the plan; How you share the cost of your covered Prescription Drug benefit; and Other important information such as eligibility, complaints and appeals, termination, and general administration of the plan. A few important notes to consider before moving forward: Unless otherwise indicated, you refers to you and your covered dependents. Your Prescription Drug plan pays benefits only for Prescription Drug expenses described in this Certificate as Covered Benefits that are Medically Necessary. This Certificate applies to coverage only and does not restrict your ability to receive Prescription Drugs that are not or might not be covered benefits under this Prescription Drug plan. Store this Certificate in a safe place for future reference. Notice The plan does not cover all Prescription Drugs, medications and supplies. Refer to the Limitations section of this coverage and Exclusions section of your Certificate. Covered Benefits are subject to cost sharing requirements as described in the cost sharing sections of this coverage and in your Schedule of Benefits. Specialty Care Prescription Drug refills will only be covered when obtained through Aetna s Specialty Network Pharmacy. This plan covers only certain Prescription Drugs in accordance with the plan that you elected and the Preferred Drug Guide (Formulary). This plan does not cover all Prescription Drugs. -58-

59 Accessing Pharmacies and Benefits This plan provides access to Covered Benefits through a network of pharmacies, vendors or suppliers. Aetna has contracted for these Network Pharmacies to provide Prescription Drugs and other supplies to you. Obtaining your benefits through Network Pharmacies has many advantages. Benefits and cost sharing may vary by the type of network pharmacy where you obtain your Prescription Drug and whether or not you purchase a brand-name or generic drug. Network pharmacies include retail, mail order and specialty Pharmacies. To better understand the choices that you have with your plan, please carefully review the following information. Accessing Network Pharmacies and Benefits You may select a Network Pharmacy from the Aetna Network Pharmacy Directory or by logging on to Aetna s website at You can search Aetna s online directory, DocFind, for names and locations of Network Pharmacies. If you cannot locate a Network Pharmacy in your area call Member Services. You must present your ID card to the Network Pharmacy every time you get a Prescription filled to be eligible for network Covered Benefits. The Network Pharmacy will calculate your claim online. You will pay any deductible, copayment or coinsurance directly to the Network Pharmacy. You do not have to complete or submit claim forms. The Network Pharmacy will take care of claim submission. Emergency Prescriptions When you need a Prescription filled in an emergency or urgent care situation, or when you are traveling, you can obtain network benefits by filling your Prescription at any Network Retail Pharmacy. The Network Pharmacy will fill your Prescription and only charge you your plan s cost sharing amount. If you access a Non-Participating Pharmacy you will pay the full cost of the prescription and will need to file a claim for reimbursement. You will be reimbursed for your Covered Benefits up to the cost of the Prescription less your plan s cost sharing for network benefits. Coverage for Prescription Drugs obtained from a Non-Participating Pharmacy is limited to those obtained in connection with Emergency Care and out-of-area Urgent Care services. Availability of Providers Aetna cannot guarantee the availability or continued network participation of a particular Pharmacy. Either Aetna or any Network Pharmacy may terminate the provider contract. -59-

60 Cost Sharing for Network Benefits You share in the cost of your benefits. Cost Sharing amounts and provisions are described in the Schedule of Benefits. You will be responsible for the Copayment for each Prescription or refill as specified in the Schedule of Benefits. The Copayment is payable directly to the Network Pharmacy at the time the Prescription is dispensed. What the Pharmacy Benefit Covers The plan covers charges for outpatient Prescription Drugs for the treatment of an illness or injury, subject to the Limitations section of this coverage and the Medical Benefit and Pharmacy Benefit Exclusions sections of the Certificate. Prescriptions must be written by a Prescriber licensed to prescribe federal legend prescription drugs. This plan covers only certain Prescription Drugs in accordance with the plan that you elected and the Preferred Drug Guide (Formulary). This plan does not cover all Prescription Drugs. You may minimize your out-of-pocket expenses by selecting a Generic Prescription Drug when available. Brand-name Prescription drugs that are not listed on the Preferred Drug Guide (Formulary) are excluded from coverage unless a medical exception is approved by Aetna. Refer to the Medical Exceptions described below for details. If it is Medically Necessary for you to use a Prescription Drug not on the Preferred Drug Guide (Formulary), you or your Prescriber must request coverage as a medical exception. Your Prescription Drug benefit may be subject to pharmacy management programs including, but not limited to precertification, step therapy, quantity limits and drug utilization review, which may include limiting access of Prescription Drugs prescribed by a specific Provider. Such limitation may be enforced in the event that Aetna identifies an unusual pattern of claims for Covered Benefits. Refer to Understanding Pharmacy Precertification for further information. Retail Pharmacy Benefit Outpatient Prescription Drugs are covered when dispensed by a retail pharmacy. Each Prescription is limited to the maximums shown in the Schedule of Benefits. Mail Order Pharmacy Benefit Outpatient Prescription Drugs are covered when dispensed by a mail order pharmacy that is a Network Pharmacy. Each Prescription is limited to a maximum supply when filled at a mail order Pharmacy that is a Network Pharmacy. The maximums are shown in the Schedule of Benefits. Specialty Care Prescription Drug Benefit Specialty Care Prescription Drugs (Specialty Care Drugs) are covered only when dispensed through a retail Network Pharmacy or a Specialty Network Pharmacy. Refer to Aetna s website, to review the list of covered Specialty Care Drugs. You are required to obtain Specialty Care Drugs at a Specialty Network Pharmacy for all Prescription Drug refills after the initial fill. -60-

61 Other Covered Pharmacy Benefits The following Prescription Drugs, medications and supplies are also Covered Benefits under this Coverage. Off-Label Use U.S. Food and Drug Administration (FDA) approved Prescription Drugs will be covered when the offlabel use of the drug has not been approved by the FDA for your symptom(s). Off-label use means the prescription of a drug for a treatment other than those treatments stated in the labeling approved by the FDA. Coverage of off-label use of these drugs may, in Aetna s discretion, be subject to precertification, step therapy or other requirements or limitations. Contraceptives Covered Benefits include charges made by a Pharmacy for the following contraceptive methods when prescribed by a Prescriber and the Prescription is submitted to the pharmacist for processing: Female contraceptives that are Prescription drugs including emergency contraceptives that are included on the Preferred Drug List (Formulary). FDA-approved female OTC contraceptives when prescribed by a Physician to include sponges, spermicide and female condoms. Female contraceptive devices. Benefits are payable under your medical or Pharmacy benefit depending on the type of expense and how and where the expense is incurred. Benefits are payable under your medical plan when charges are made by a Physician to insert or remove a Prescription drug or device. Refer to your Schedule of Benefits for the Female Contraceptives - Copayment and Deductible Waiver provision for more information. Oral Infertility Drugs Oral infertility prescription drugs used for the purpose of treating infertility, such as Progesterone. Prescription Eye Drop Refill Aetna will provide coverage for a refill of prescription eye drops: In accordance with guidance for early refill of topical ophthalmic products provided to Medicare Part D plan sponsors by the Center for Medicare and Medicaid Services; and If: - The prescriber indicates on the original prescription that additional quantities of the prescription eye drops are needed. - The refill requested by the Member does not exceed the number of additional quantities indicated on the original prescription by the prescriber. - The prescription eye drops prescribed by the prescriber are covered by the Certificate. -61-

62 Understanding Pharmacy Precertification Precertification is required for certain outpatient Prescription Drugs. Prescribers must contact Aetna or an affiliate to request and obtain coverage for such Prescription Drugs. The list of drugs requiring precertification is subject to periodic review and modification by Aetna. An updated copy of the list of drugs requiring precertification shall be available upon request or may be accessed on line and can be found in the Aetna Preferred Drug Guide available online at How to Obtain Precertification If an outpatient Prescription drug requires precertification and you use a Network Pharmacy the Prescriber is required to obtain precertification for you. Aetna will let your Prescriber know if the Prescription Drug is precertified. If precertification is denied Aetna will notify you how the decision can be appealed. Step Therapy Step therapy is another form of precertification. With step therapy, certain medications will be excluded from coverage unless one or more prerequisite therapy medications are tried first or unless: the step therapy drug has not been approved by the U.S. Food and Drug Administration for the medical condition being treated; or the Prescriber obtains a medical exception; or provides supporting medical information to Aetna that the prescription drug covered by Aetna: was ordered by a prescriber for you within the past 180 days; and based on the professional judgment of the prescriber, was effective in treating your disease or medical condition. Lists of the step therapy drugs and prerequisite drugs are included in the Preferred Drug Guide (Formulary) available upon request or on your Aetna Navigator secure member websitewww.aetna.com. The list of step therapy drugs are subject to change by Aetna. Medical Exceptions Your Prescriber may seek a medical exception to obtain coverage for prescription drugs not listed on the Preferred Drug Guide (Formulary) or anytime a prescription drug is not covered. The Prescriber must submit such exception requests to Aetna. For prescription drugs or devices not on the Preferred Drug Guide (Formulary), coverage will be provided if in the judgment of the authorized prescriber: there is no equivalent prescription drug or device on the Preferred Drug Guide (Formulary); or an equivalent prescription drug or device on the Preferred Drug Guide (Formulary): has been ineffective in treating the disease or condition; or has caused or is likely to cause an adverse reaction or other harm. Coverage granted as a result of a medical exception for prescription drugs not listed on the Preferred Drug Guide (Formulary) or anytime a prescription drug is not covered shall be based on an individual, case by case Medical Necessity determination and coverage will not apply or extend to other covered persons. If approved by Aetna, you will receive the Non-Preferred benefit level as shown in your Schedule of Benefits and the exception will be provided for the duration of the prescription. -62-

63 Aetna will make a coverage determination within 72 hours after receipt of your request and will notify you or your designee and your prescriber of the decision. You, your designee or your prescriber may seek an expedited medical exception process to obtain coverage for non-covered prescription drugs in exigent circumstances. An exigency exists when you are suffering from a health condition that may seriously jeopardize your life, health or ability to regain maximum function or when you are undergoing a current course of treatment using a non-formulary drug. You, your designee, or your prescriber may submit a request for an expedited review for an exigency as described above by contacting Aetna s Precertification Department at , faxing the request to or submitting the request in writing to CVS Health ATTN: Aetna PA 1300 E Campbell Road Richardson, TX We will make a coverage determination within 24 hours after receipt of your request and will notify you or your designee and your prescriber of our decision. If approved by Aetna the exception will be granted for the duration of the prescription. If you are denied a medical exception based on the above processes, you may have the right to a third party review by an independent external review organization. If our claim decision is one for which you can seek external review, we will say that in the notice of adverse benefit determination we send you. That notice also will describe the external review process. We will notify you, your designee or your prescriber of the coverage determination of the external review no later than 72 hours after receiving your request. If the medical exception is approved, coverage will be provided for the duration of the prescription. For expedited medical exceptions in exigent circumstances, we will notify you, your designee or your prescriber of the coverage determination no later than 24 hours after receiving your request. If the expedited medical exception is approved, coverage will be provided for the duration of the exigency. Prescription Drug Benefit Limitations and Exclusions Limitations A Network Pharmacy may refuse to fill a Prescription order or refill when in the professional judgment of the pharmacist the Prescription should not be filled. The plan will not cover expenses for any Prescription Drug for which no charge is made to you. Aetna retains the right to review all requests for reimbursement and in its sole discretion make reimbursement determinations subject to the Complaint and Appeals section(s) of the Certificate. The number of Copayments you are responsible for per vial of Depo-Provera and/or Medroxyprogesterone, an injectable contraceptive, or similar type contraceptive dispensed for more than a 30 day supply, will be based on the 90 day supply level. Coverage is limited to a maximum of 5 vials per Plan Year. The plan will not pay charges for any Prescription Drug dispensed by a mail order Pharmacy for the treatment of erectile dysfunction, impotence or sexual dysfunction or inadequacy. Exclusions These Prescription Drug exclusions apply to the Outpatient Prescription Drug benefit and are in addition to the exclusions listed under your medical coverage. -63-

64 The plan does not cover the following expenses: Administration or injection of any drug, unless included in the Covered Benefits section. Any charges in excess of the benefit, day, or supply limits stated in this Certificate, unless included in the Covered Benefits section. All drugs or medications in a therapeutic drug class if one of the drugs in that Therapeutic Drug Class is not a Prescription Drug, unless Medically Necessary. Any non-emergency charges incurred outside of the United States if you traveled to such location to obtain Prescription Drugs, or supplies, even if otherwise covered under this Certificate. This also includes Prescription Drugs or supplies if: - Such prescription drug or supplies are unavailable or illegal in the United States; or - The purchase of such Prescription Drugs or supplies outside the United States is considered illegal. Any drugs or medications, services and supplies that are not Medically Necessary, as determined by Aetna, for the diagnosis, care or treatment of the illness or injury involved. Certain Brand-name Prescription Drugs but only to the extent such coverage is excluded under the plan that you elected and the Preferred Drug Guide (Formulary). Cosmetic drugs, medications or preparations used for cosmetic purposes or to promote hair growth, including but not limited to: - Health and beauty aids; - Chemical peels; - Dermabrasion; - Treatments; - Bleaching; - Creams; - Ointments or other treatments or supplies, to remove tattoos, scars or to alter the appearance or texture of the skin. Drugs given by, or while the person is an inpatient in, any healthcare facility; or any drugs provided on an outpatient basis in any such institution to the extent benefits are payable for them under another section of the Covered Benefits section. Experimental or investigational drugs or devices, except as described in the Covered Benefits section. -64-

65 This exclusion will not apply with respect to drugs that: - Have been granted treatment investigational new drug (IND); or Group c/treatment IND status; or - Are being studied at the Phase III level in a national clinical trial sponsored by the National Cancer Institute; and - Aetna determines, based on available scientific evidence, are effective or show promise of being effective for the illness. Insulin pumps or tubing or other ancillary equipment and supplies for insulin pumps. Prescription Drugs for which there is an over-the-counter (OTC) product which has the same active ingredient even if a Prescription is written, unless Medically Necessary. Brand-name Prescription drugs unless the drug is included on the Preferred Drug Guide (Formulary) or a medical exception is granted. Prescription orders filled prior to the effective date or after the termination date of coverage under this Certificate except during the Extension of Benefits. Refills over the amount specified by the Prescription order. Before recognizing charges, Aetna may require a new Prescription or proof as to need, if a Prescription or refill appears excessive under accepted medical practice standards. Refills dispensed more than one year from the date the latest Prescription order was written, or as otherwise allowed by applicable law of the jurisdiction in which the drug is dispensed. Replacement of lost or stolen Prescriptions. Supplies, devices or equipment of any type, except as specifically provided in the Covered Benefits section. -65-

66 TERMINATION OF COVERAGE A Member s coverage under this Certificate will terminate upon the earliest of any of the conditions listed below. Termination of Subscriber Coverage A Subscriber s coverage will terminate for any of the following reasons: Employment terminates; The Group Agreement terminates; The Subscriber is no longer eligible as outlined in this Certificate; The Subscriber becomes covered under an alternative health benefit plan or under any other plan which is offered by, through, or in connection with, the Contract Holder in lieu of coverage under this Certificate. Termination of Dependent Coverage A Covered Dependent s coverage will terminate for any of the following reasons: A Covered Dependent is no longer eligible, as outlined in this Certificate; The Group Agreement terminates; or The Subscriber s coverage terminates. Coverage for a dependent child covered under a qualified medical support order, as set forth in this Certificate may not be terminated unless written evidence is provided to Aetna that: The order is no longer in effect; or The child has been or will be enrolled under other reasonable health insurance coverage which will take effect not later than the effective date of the disenrollment; or The Contract Holder has eliminated family health coverage for all of its employees; or The Contract Holder no longer employs the parent under whose name the child has been enrolled for coverage except to the extent that if the parent elects to exercise the provision of the Consolidated Omnibus Budget Reconciliation act of 1985 (COBRA) then coverage will be provided for the Covered Dependent consistent with the Contract Holder s plan relating to postemployment medical coverage for dependents. -66-

67 Aetna will provide Member with a notice of termination of coverage that includes the reason for termination at least 30 prior to Member s last day of coverage. The notice will include the termination effective date. Coverage of a dependent will not terminate if the Subscriber becomes enrolled under a group Medicare Advantage plan offered by Aetna or one of its affiliates. However, the dependents will terminate if the Subscriber s coverage terminates under the Medicare Advantage plan. Member s effective date of termination of coverage will be: When no longer eligible, the last day of the month following the month in which notice of eligibility is sent to Member, unless Member requests an earlier termination date. For non-payment of premium, the last day of the grace period. When Member changes from one qualified plan to another, the day before the effective date of coverage under the new qualified plan. -67-

68 CONTINUATION AND EXTENSION OF BENEFITS COBRA Continuation Coverage COBRA is the Consolidated Omnibus Budget Reconciliation Act of 1985, and related amendments ( COBRA ). The description of COBRA which follows is intended only to summarize the Member s rights under the law. Coverage provided under this Certificate offers no greater COBRA rights than COBRA requires and should be construed accordingly. COBRA permits eligible Members or eligible Covered Dependents to elect to continue group coverage as follows: Employees and their Covered Dependents will not be eligible for the continuation of coverage provided by this section if the Contract Holder is exempt from the provisions of COBRA. Minimum Size of Group: The Contract Holder must have normally employed 20 or more employees on a typical business day during the preceding Plan Year. This refers to the number of employees employed, not the number of employees covered by a health plan, and includes full-time and part-time employees. Loss of coverage due to termination (other than for gross misconduct) or reduction of hours of employment: Member may elect to continue coverage for 18 months after eligibility for coverage under this Certificate would otherwise cease. Loss of coverage due to: - Divorce or legal separation, or - Subscriber's death, or - Subscriber's entitlement to Medicare benefits, or, - Cessation of Covered Dependent child status under the Eligibility and Enrollment section of this Certificate: The Member may elect to continue coverage for 36 months after eligibility for coverage under this Certificate would otherwise cease. Continuation coverage ends at the earliest of the following events: - The last day of the 18 month period. - The last day of the 36 month period. - The first day on which timely payment of Premium is not made subject to the Premiums section of the Group Agreement. - The first day on which the Contract Holder ceases to maintain any group health plan. -68-

69 - The first day, after the day COBRA coverage has been elected, on which a Member is actually covered by any other group health plan. In the event the Member has a preexisting condition, and the Member would be denied coverage under the new plan for a preexisting condition, continuation coverage will not be terminated until the last day of the continuation period, or the date upon which the Member s preexisting condition becomes covered under the new plan, whichever occurs first. - the date, after COBRA coverage has been elected, when the Member is entitled to Medicare. Extensions of Coverage Periods: - The 18 month coverage period may be extended if an event which would otherwise qualify the Member for the 36 month coverage period occurs during the 18 month period, but in no event may coverage be longer than 36 months from the event which qualified the Member for continuation coverage initially. - In the event that a Member is determined, within the meaning of the Social Security Act, to be disabled and notifies the Contract Holder within 60 days of the Social Security determination and before the end of the initial 18 month period, continuation coverage for the Member and other qualified beneficiaries may be extended up to an additional 11 months for a total of 29 months. The Member must have become disabled during the first 60 days of the COBRA continuation coverage. Responsibility of the Contract Holder to provide Member with notice of Continuation Rights: The Contract Holder is responsible for providing the necessary notification to Members, within the defined time period, as required by COBRA. Responsibility to pay Premiums to Aetna: The Subscriber or Member will only have coverage for the 60 day initial enrollment period if the Subscriber or Member pays the applicable Premium charges due within 45 days of submitting the application to the Contract Holder. Premiums due Aetna for the continuation of coverage under this section shall be due in accordance with the procedures of the Premiums section of the Group Agreement and shall be calculated in accordance with applicable federal law and regulations. Continuation Coverage for Dependents after Subscriber s Death If a Subscriber dies while covered under this Certificate, any coverage then in force for the Covered Dependents will be continued, provided Premium payments continue to be made. The Contract Holder will provide the Covered Dependent with instructions on how to continue coverage. Any Covered Dependent's coverage, including a spouse's, will cease upon the earliest of: The end of the 18th month period right after the Subscriber's death; With respect to a Covered Dependent child the date on which the child no longer meets the eligibility requirements as outlined in this Certificate; A Covered Dependent becomes eligible for similar coverage under any other plan providing group health benefits; A Covered Dependent becomes entitled to benefits under Title XVIII of the Social Security Act; -69-

70 The spouse elects to terminate coverage under this Certificate; When the Contract Holder no longer provides coverage to any of its eligible enrollees; or Any required contributions cease. If coverage is being continued for a Covered Dependent, a Subscriber s child born after the Subscriber's death will also be covered. Continuing Coverage for Divorced Spouses and Covered Dependents If a Subscriber should divorce while covered under this Plan, any coverage then in force for the Covered Dependents will continue as long as: The Subscriber was covered at the time of your divorce, A request is made for continued coverage within 60 days after your divorce; and Payment is made for the coverage. If coverage is being continued for a Covered Dependent, a Subscriber s child born after the Subscriber's divorce will also be covered. Covered Dependent coverage will end when the first of the following occurs: With respect to a Covered Dependent child, the date on which the child would no longer be covered had the divorce not occurred; The date on which the Covered Dependent becomes eligible for hospital, medical, or surgical benefits under an insured or self-insured group health benefit program or plan, other than this plan; that is written on an expense-incurred basis or is with a health maintenance organization; The date the Covered Dependent becomes entitled to benefits under Title XVIII of the Social Security Act; The Covered Dependent elects to terminate coverage under this Plan; or Any required contributions stop; and For the Subscriber s spouse, the date the divorced spouse remarries. Continuing Coverage for Voluntarily and Involuntarily Terminated Employees If a Subscriber s employment should be voluntarily or involuntarily terminated while covered under this Plan, any coverage in force will continue as long as: The Subscriber was covered at the time of your termination, A request is made for continued coverage within 45 days after your termination; and Payment is made for the coverage. -70-

71 Coverage will end when the first of the following occurs: The end of the 18 month period following termination of employment; The date on which the Contract Holder ceases to provide benefits to its eligible employees; With respect to a Covered Dependent child, the date on which the child would no longer be covered had the termination of employment not occurred; The Subscriber becomes eligible for comparable benefits under any other group plan; The Subscriber becomes entitled to benefit under Title XVIII of the Social Security Act; The Subscriber elects to terminate coverage under the Certificate; or Any required contributions stop. Continuation of Coverage During Temporary Lay-off or Approved Leave of Absence If a Subscriber's coverage would terminate due to a temporary lay-off or an approved leave of absence, coverage may be continued for up to 365 days, or as otherwise agreed to between Aetna and Contract Holder, if the Contract Holder: (1) pays the Premium for such continued coverage; and (2) provides continued coverage from Aetna or its other sponsored health benefit plans to all eligible enrollees in the same class as the Subscriber whose coverage would otherwise terminate because of a temporary lay-off or approved leave of absence. Extension of Benefits Upon Total Disability Any Member who is Totally Disabled on the date coverage under this Certificate terminates is covered in accordance with the Certificate. This extension of benefits shall only: Provide Covered Benefits that are necessary to treat medical conditions causing or directly related to the disability as determined by Aetna; and Remain in effect until the earlier of the date that: - The Member is no longer Totally Disabled; - The Member has exhausted the Covered Benefits available for treatment of that condition; - The Member has become eligible for coverage from another health benefit plan which does not exclude coverage for the disabling condition and the coverage is provided at a cost to the Member that is less than or equal to the cost to the Member of the extended benefit and will not result in an interruption of benefits; or - After a period of 12 months in which benefits under such coverage are provided to the Member. The extension of benefits shall not extend the time periods during which a Member may enroll for continuation coverage, expand the benefits for such coverage, nor waive the requirements concerning the payment of Premium for such coverage -71-

72 ADMINISTRATIVE COMPLAINT, GRIEVANCE AND APPEAL PROCEDURE The following definitions apply to this procedure: Adverse Benefit Determination A denial; reduction; termination of; or failure to provide or make payment (in whole or in part) for a benefit, service or supply. Such Adverse Benefit Determination may be based on, among other things: A coverage decision involving: An initial determination by a carrier or a representative of the carrier that results in non-coverage of a health care service; A determination by the carrier that an individual is not eligible for coverage under the carrier s health benefit plan; or Any determination by a carrier that results in the rescission of an individual s coverage under the health benefit plan. A coverage decision includes non-payment of all or part of a claim. A coverage decision does not include an adverse decision. An adverse decision, involving the results of any utilization review determination by a private review agent; a carrier; or a health care provider acting on behalf of a carrier; that: A proposed or delivered health care service, which would otherwise be covered under the Member s contract, is not, or was not, Medically Necessary; appropriate; or efficient; and May result in non-coverage of the health care service. An adverse decision does not include a decision concerning a person s status as a Member. Appeal An oral or written protest filed by a Member, a Member s Representative or a health care provider under Aetna s internal appeal process regarding a request to reconsider an Adverse Benefit Determination involving a coverage decision. Appeal Decision A final determination that arises from an appeal filed with Aetna of a coverage decision concerning a Member. Administrative Complaint An oral or written contact from the Member which expresses a dissatisfaction regarding: The direct provision or quality of care by a participating health care provider; The quality of administrative service provided by a participating health care provider; The quality of administrative service provided by Aetna ; The use of his or her protected health information; or A plan benefit, billing, eligibility, or contract provision that does not involve a request to review an adverse benefit determination. -72-

73 Complaint A protest filed by a Member, a Member s Representative or a health care provider on behalf of a Member, with the Maryland Insurance Commissioner. It involves a coverage decision; appeal decision; adverse decision; or grievance decision. The address for filing a complaint for a coverage or appeal decision is: Maryland Insurance Administration Life and Health Consumer Complaint Investigation Unit 200 St. Paul Place, Suite 2700 Baltimore, Maryland Fax: (410) Phone: (410) or (800) (toll free) TDD Users: (800) (toll free) The address for filing a complaint for an adverse or grievance decision is: Maryland Insurance Administration Appeal and Grievance Unit 200 St. Paul Place, Suite 2700 Baltimore, Maryland Fax: (410) Phone: (410) or (800) (toll free) TDD Users: (800) (toll free) Concurrent Care Claim A previously pre-authorized claim for an ongoing course of treatment that is provided over a period of time or number of treatments. Emergency Case A case involving an adverse decision for which an expedited review is requested. Filing Date The earlier of: 5 days after the date of mailing; or the date of receipt. Grievance An oral or written protest filed by a Member, a Member s Representative or a health care provider on behalf of a Member, with a carrier. It must be filed through Aetna s internal grievance process for adverse decisions. Grievance Decision A final determination by Aetna that arises from a grievance filed by a Member, a Member s Representative or a health care provider on behalf of the Member under Aetna's internal grievance process for adverse decisions. -73-

74 Health Advocacy Unit The Health Education and Advocacy Unit. It is part of the Maryland Division of Consumer Protection, Office of the Attorney General. The address is: Health Education and Advocacy Unit Consumer Protection Division Office of the Attorney General 200 St. Paul Place, 16 th Floor Baltimore, Maryland Fax: (410) Phone: (410) or (877) (toll free) - Health Care Provider A person who is licensed or otherwise authorized in Maryland, to provide health care services in the ordinary course of business or practice of a profession and is a treating health care provider of a Member; or a hospital. Health Care Service A health or medical care procedure; or service; rendered by a health care provider that: provides testing; diagnosis; or treatment; on a human disease or dysfunction; or dispenses drugs; medical devices; medical appliances; or medical goods; for the treatment of a human disease or dysfunction. Member s Representative An individual who has been authorized by the Member to file an appeal, a grievance or a complaint on the Member s behalf. Pre-service Claim A claim for a benefit that requires pre-authorization of the benefit in advance of obtaining medical care. Post-service Claim A claim for a benefit that is not a pre-service claim. Urgent Medical Condition A medical condition, including a physical condition; a mental condition; or a dental condition; where the absence of medical attention within 72 hours could reasonably be expected by an individual, acting on behalf of Aetna, applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine, to result in: Placing the Member's life or health in serious jeopardy; The inability of the Member to regain maximum function; Severe pain that cannot be adequately managed without medical treatment; Serious impairment to bodily function; Serious dysfunction of any bodily organ or part; The Member remaining seriously mentally ill with symptoms that cause the Member to be a danger to self or others; or In the case of a pregnant woman, causing serious jeopardy to the health of the fetus; or -74-

75 A medical condition, including a physical condition; a mental condition; or a dental condition; where the absence of medical attention within 72 hours, in the opinion of a health care provider with knowledge of the Member's medical condition, would subject the Member to severe pain that cannot be adequately managed without the care or treatment that is the subject of a coverage decision. Administrative Complaints If you have an administrative complaint, please contact Aetna either verbally or in writing. The address and telephone number are listed on your plan documents; brochure; or identification card. Administrative complaints will be resolved within 30 calendar days of receipt. Initial Decisions CLAIMS DETERMINATION - MEDICAL COVERAGE Claims Involving urgent medical conditions: Aetna will make notification of a claim involving an urgent medical condition as soon as possible, but not more than 72 hours after the claim is made. If more information is needed to make a claim determination involving an urgent medical condition, the Aetna will notify the Member within 24 hours of receipt of the claim. The Member has 48 hours after receiving such notice to provide Aetna with the additional information. Aetna will notify the Member within 48 hours of the earlier of the receipt of the additional information or the end of the 48 hour period given the Member to provide Aetna with the information. If the Member fails to follow plan procedures for filing a claim, Aetna will notify the Member within 24 hours following the failure to comply. Concurrent Care Claim Extension: Following a request for a Concurrent Care Claim Extension, Aetna will make notification of a claim determination for emergency or urgent care as soon as possible but not later than 24 hours, with respect to emergency or urgent care provided the request is received at least 24 hours prior to the expiration of the approved course of treatment, and 1 working day with respect to all other care, following a request for a Concurrent Care Claim Extension. Concurrent Care Claim Reduction or Termination: Aetna will make notification of a claim determination to reduce or terminate a previously approved course of treatment with enough time for the Member to file an appeal. Aetna will not deny reimbursement to a health care provider for the pre-authorized or approved service delivered to the Member unless: the information submitted to Aetna regarding the service to be delivered to the Member was fraudulent or intentionally misrepresentative; critical information requested by Aetna regarding the service to be delivered to the Member was omitted such that Aetna s determination would have been different had it known the critical information; a planned course of treatment for the Member that was approved by Aetna was not substantially followed by the health care provider; or on the date the pre-authorized or approved service was delivered: the Member was not covered by Aetna; Aetna maintained an automated eligibility verification system that was available to the contracting provider by telephone or via the Internet; and according Aetna the verification system, the Member was not covered by Aetna. -75-

76 Pre-Service Claims: Aetna will make notification of a claim determination as soon as possible but not later than 2 working days after receipt of the information necessary to make the determination. If Aetna needs additional information to make a claim determination, Aetna will notify the Member of the specific information required within 3 calendar days of the filing date of the pre-service claim. Post-Service Claims: Aetna will make notification of a claim determination as soon as possible but not later than 30 calendar days after the post-service claim is made. If Aetna needs additional information to make a claim determination, Aetna will notify the Member of the receipt and status of the claim and include: the reason why all or part of the claim has not been paid and what specific information is needed to render a final claim determination. Coverage Decisions If Aetna renders a coverage decision, Aetna will, within 30 calendar days of the date of the coverage decision, send a written notice to the Member, the Member s Representative and the health care provider on behalf of such Member. The notice will include: The specific factual basis for the decision stated in detail in clear, understandable language. A statement advising the Member, the Member s Representative or the health care provider on behalf of the Member that they have the right to file an appeal of the coverage decision with Aetna. A statement advising the Member, the Member s Representative or the health care provider that they may file a complaint with the Maryland Insurance Commissioner without first exhausting Aetna s internal appeals process, if the coverage decision involves an urgent medical condition for which care has not been rendered. The Commissioner s address, telephone number and facsimile number. A statement advising the Member, the Member s Representative or the health care provider on behalf of the Member that the Health Advocacy Unit is available to help the Member in both mediating and filing an appeal under Aetna s internal appeal process. The contact information for the Health Advocacy Unit also will be provided. Level I Appeal of a Coverage Decision If, after reviewing the information provided by Aetna concerning the coverage decision, the Member wishes to have the decision reconsidered, the Member, the Member s Representative or the health care provider on behalf of the Member can file a Level I appeal of the coverage decision no later than 180 calendar days after receipt of the notice regarding the coverage decision. An appeal of a coverage decision may be filed orally or in writing. The appeal should contain sufficient information for Aetna to investigate and render an appeal decision. Appeals of coverage decisions will be handled as described below. -76-

77 Aetna will review and render an appeal decision and will forward a written notice stating the results of the review to the Member, the Member s Representative and the health care provider on behalf of the Member. The appeal will be reviewed by Aetna personnel not involved in making the initial coverage decision. The appeal decision will be rendered: With respect to claims involving an urgent medical condition, within 24 hours of the filing date of the request. With respect to pre-service claims, within 15 calendar days of the filing date of the request. With respect to post-service claims, within 30 calendar days of the filing date of the request. The notice will include: The specific factual basis for the decision stated in detail in clear, understandable language. If the coverage decision is upheld, a statement advising the Member, the Member s Representative or the health care provider on behalf of the Member that they have the option of requesting an Appeal Hearing as described in the Level II Appeal Hearing section A statement advising the Member, the Member s Representative or the health care provider that, if they choose not to request the optional Appeal Hearing, that they have the right to file a complaint with the Maryland Insurance Commissioner within 4 months after receipt of the appeal decision. The contact information for the Maryland Insurance Commissioner also will be provided. A statement advising the Member that the Health Advocacy Unit is available to assist the Member or the Member s Representative in filing a complaint with the Maryland Insurance Commissioner. The contact information for the Health Advocacy Unit also will be provided. Level II Appeal Hearing of an Appeal Decision A Member, a Member s Representative or a health care provider on behalf of a Member may request a Level II Appeal Hearing to dispute an appeal decision. Level II Appeal Hearings are voluntary. If the Member, the Member s Representative or the health care provider on behalf of the Member decides not to request a Level II Appeal Hearing, they still have the option of filing a complaint with the Maryland Insurance Commissioner. Please refer to the time period specified in Level I Appeal of a Coverage Decision section. For appeal decisions, the Level II process begins when the Member, the Member s Representative or the health care provider on behalf of the Member, is not satisfied with the Level I appeal decision and requests, either orally or in writing, a Level II Appeal Hearing. The Member, the Member s Representative or the health care provider has 10 days from the date of receipt of the Level I appeal decision to request a Level II Appeal Hearing. Upon receipt of a request for a Level II Appeal Hearing, Aetna will provide the Member filing the request with the procedures governing Appeal Hearings. The Member will be notified of their right to have an uninvolved Aetna representative available to help them understand the Appeal Hearing process. A review body at the local market (hereinafter the Appeal Hearing Panel ) will be formed to handle the Appeal Hearing. The reviewers must not have participated in any prior review determinations. The composition of the review body must be peers of the treating health care provider (physician to physician; chiropractor to chiropractor). -77-

78 Aetna will hold Appeal Hearings in its offices as needed, but no more than 20 working days after the filing date of the Appeal Hearing request. Written notification will be sent to the Member indicating the time; date; and location; of the hearing. In the event a Member is unable to attend the hearing on the scheduled hearing day, the dispute will be heard in the Member s absence. The Member will have the right to the following: Attend the Appeal Hearing. Question the representative of Aetna designated to appear at the hearing and any other witnesses. Present their case. Be assisted or represented by a person of the Member s choice. Submit written material in support of their dispute. The Member may bring a physician or other expert(s) to testify on the Member s behalf. Aetna will also have the right to present witnesses. Counsel for the Member may present the Member s case and question witnesses; if the Member is so represented. Similarly, Aetna also may choose to be represented by counsel. The Appeal Hearing Panel will have the right to question Aetna representative, the Member and any other witnesses. The Appeal Hearing will be informal. It will not apply formal rules of evidence in reviewing documentation or accepting testimony at the hearing. The Chair of the Appeal Hearing Panel will have the right to exclude redundant testimony or excessive argument by any party or witness. A written record of the Appeal Hearing will be made by stenographic transcription. All testimony will be under oath. Before the record is closed, the Chair of the Appeal Hearing Panel will ask both the Member and Aetna representative (or their counsel) whether there is any additional evidence or argument which the party wishes to present to the Appeal Hearing Panel. Once all evidence and arguments have been received, the record of the Appeal Hearing will be closed. The deliberations of the Appeal Hearing Panel will be confidential and will not be transcribed. The Appeal Hearing Panel will render a written decision within 5 working days of the conclusion of the Appeal Hearing. For final appeal decisions, the written decision will contain: The specific factual basis for the decision stated in detail in clear, understandable language. A statement advising the Member, the Member s Representative or the health care provider that they have the right to file a complaint with the Maryland Insurance Commissioner within 4 months after receipt of the final appeal decision. The contact information for the Maryland Insurance Commissioner also will be provided. A statement advising the Member that the Health Advocacy Unit is available to assist the Member or the Member s Representative in filing a complaint with the Maryland Insurance Commissioner. The contact information for the Health Advocacy Unit also will be provided. -78-

79 Adverse Decisions If Aetna renders an adverse decision on a non-emergency case, Aetna will orally communicate this adverse decision to the Member, the Member s Representative or the health care provider on behalf of the Member. Aetna also will, within 5 working days of the date of the adverse decision, send a written notice to the Member, the Member s Representative and the health care provider on behalf of the Member. The notice will include: The specific factual basis for the decision stated in detail in clear, understandable language. A reference to the specific criteria and standards, including interpretive guidelines, on which the adverse decision was based. The name, business address and business telephone number of the medical director that made the adverse decision. The details of the internal grievance process and procedures. A statement advising the Member, the Member s Representative or the health care provider that they may, within 4 months of receiving the notice of a grievance decision (please refer to the Level I Filing a Grievance of an Adverse Decisions section), file a complaint with the Maryland Insurance Commissioner. The contact information for the Maryland Insurance Commissioner also will be provided. A statement advising the Member, the Member s Representative or the health care provider that they may file a complaint with the Maryland Insurance Commissioner without first filing a grievance if: - Aetna waives the requirement that Aetna s internal grievance process be exhausted before filing a complaint with the Maryland Insurance Commissioner; - Aetna has failed to comply with any of the requirements of its internal grievance process as described herein; or - The Member, the Member s Representative or the health care provider provides sufficient information and supporting documentation in the complaint that shows a compelling reason to do so. The compelling reason must show that the potential delay in receiving the health care service until after the Member, the Member s Representative or the health care provider on behalf of the Member, has exhausted Aetna s internal grievance process and obtained a final decision, could result in: - Loss of life; - Serious impairment to a bodily function; - Serious dysfunction of a bodily organ; or - The Member remaining seriously mentally ill with symptoms that cause the Member to be a danger to him/herself or others. When filing a complaint with the Maryland Insurance Commissioner the Member or the Member s Representative will be required to authorize the release of any medical records of the Member that may be required to be reviewed for the purpose of reaching a decision on the complaint. The contact information for the Maryland Insurance Commissioner also will be provided. In the case of a post-service adverse decision there is no compelling reason to bypass Aetna s internal grievance procedure and file a complaint with the Maryland Insurance Commissioner. A statement advising the Member, the Member s Representative or the health care provider on behalf of the Member, that the Health Advocacy Unit: Is available to help the Member with filing a grievance under the carrier s internal grievance process; -79-

80 Is not available to represent or accompany the Member during the procedures of the internal grievance process; and Can help the Member in mediating a resolution of the adverse decision with the carrier, but that any time during the mediation, the Member, the Member s Representative or the health care provider on behalf of the Member, may file a grievance. The contact information for the Health Advocacy Unit also will be provided. Level I Filing a Grievance of an Adverse Decision If, after reviewing the information provided by Aetna, the Member, the Member s Representative or the health care provider acting on behalf of the Member wishes to have the adverse decision reconsidered, the Member, the Member s Representative or the health care provider on behalf of the Member can file a grievance within the next 180 calendar days. A grievance may be filed orally or in writing. The grievance should contain sufficient information for Aetna to investigate and render a decision. All grievances will be handled as described below. The appropriate Aetna Grievance Unit will review all of the information submitted. It will gather any additional information necessary to prepare and render a decision about the grievance. If there is insufficient information available to make a decision, the Grievance Unit will notify the Member, the Member s Representative or the health care provider on behalf of the Member, of the need for additional information. This will occur within 5 working days of the filing date of the grievance. The Grievance Unit will help the Member, the Member s Representative or the health care provider to obtain the information without further delay. If necessary for the review, it also will send an authorization for release form to the Member for the purpose of obtaining medical records or other information. Except for an emergency case (please see Expedited Review of Adverse Decisions ) Aetna's Grievance Unit will review and render a grievance decision within: 24 hours of the filing date of the request with respect to a claim involving an urgent medical condition; 15 calendar days of the filing date of the request with respect to a pre-service claim; 30 calendar days of the filing date of the request with respect to a post-service claim. The Grievance Unit will orally communicate this grievance decision to the Member, the Member s Representative or the health care provider on behalf of the Member. A written notice stating the results of the review by the appropriate Grievance Unit will be forwarded to the Member, the Member s Representative and the health care provider on behalf of the Member. This will occur within 5 working days of the date of the decision. This notice will include: The specific factual basis for the decision stated in detail in clear, understandable language. A reference to the specific criteria and standards, including interpretive guidelines, on which the grievance decision was based. The name, business address and business telephone number of the medical director that made the grievance decision. If the adverse decision is upheld, a statement advising the Member, the Member s Representative or the health care provider on behalf of the Member that they have the option of requesting a Committee Review as described in the Level II Committee Review section, within the next 10 days after receipt of the notice. -80-

81 A statement advising the Member, the Member s Representative or the health care provider that, if they choose not to request the optional Committee Review, they have the right to file a complaint with the Maryland Insurance Commissioner, within 4 months after receipt of the grievance decision. The contact information for the Maryland Insurance Commissioner also will be provided. A statement advising the Member that the Health Advocacy Unit is available to assist the Member or the Member s Representative in filing a complaint with the Maryland Insurance Commissioner. The contact information for the Health Advocacy Unit also will be provided. - A statement informing the Member about where this information can be found in the policy; enrollment materials; or other evidence of coverage. A complaint also may be filed with the Maryland Insurance Commissioner, using the contact information referenced above, if Aetna does not render a grievance decision within 15 calendar days of the filing date of the pre-service grievance, and 30 calendar days of the filing date of the post-service grievance. Level II Committee Review of a Grievance Decision A Member, a Member s Representative or a health care provider on behalf of a Member may request a Level II Committee Review to dispute a grievance decision. Level II Committee Reviews are voluntary. If the Member, the Member s Representative or the health care provider on behalf of the Member decides not to request a Level II Committee Review, they still have the option of filing a complaint with the Maryland Insurance Commissioner. Please refer to the time periods specified in Level I Filing a Grievance of an Adverse Decision section. For grievances, the Level II process begins when the Member, the Member s Representative or the health care provider on behalf of the Member, is not satisfied with the Level I grievance decision and requests, either orally or in writing, a Level II Committee Review. To request a Level II Committee Review, the Member, the Member s Representative or the health care provider must request a Committee Review within 10 days from the date of oral notification of the Level I grievance decision. The Member, the Member s Representative or the health care provider also must agree, in writing, to give Aetna a 30 working day extension to render a final grievance decision. Upon receipt of a request for a Level II Committee Review, Aetna will provide the Member filing the request with the procedures governing Committee Reviews. The Member will be notified of the Member s right to have an uninvolved Aetna representative available to help the Member in understanding the Committee Review process. A review body at the local market (hereinafter the Committee Review Panel ) will be formed to handle the Committee Review. The reviewers must not have participated in any prior review determinations. The composition of the review body must be peers of the treating health care provider (physician to physician; chiropractor to chiropractor). If the dispute involves a medical necessity issue, they must be board certified or board eligible in a discipline pertinent to the issue under review. Aetna will hold Committee Reviews in its offices as needed, but no more than 20 working days after the filing date of the Committee Review request. Written notification will be sent to the Member indicating the time; date; and location; of the hearing. In the event a Member is unable to attend the hearing on the scheduled hearing day, the dispute will be heard in the Member s absence. -81-

82 The Member will have the right to the following: Attend the Committee Review. Question the representative of Aetna designated to appear at the review and any other witnesses. Present their case. Be assisted or represented by a person of the Member s choice. Submit written material in support of their dispute. The Member may bring a physician or other expert(s) to testify on the Member s behalf. Aetna will also have the right to present witnesses. Counsel for the Member may present the Member s case and question witnesses; if the Member is so represented. Similarly, Aetna also may choose to be represented by counsel. The Committee Review Panel will have the right to question Aetna representative, the Member and any other witnesses. The Committee Review will be informal. It will not apply formal rules of evidence in reviewing documentation or accepting testimony at the review. The Chair of the Committee Review Panel will have the right to exclude redundant testimony or excessive argument by any party or witness. A written record of the Committee Review will be made by stenographic transcription. All testimony will be under oath. Before the record is closed, the Chair of the Committee Review Panel will ask both the Member and Aetna representative (or their counsel) whether there is any additional evidence or argument which the party wishes to present to the Committee Review Panel. Once all evidence and arguments have been received, the record of the Committee Review will be closed. The deliberations of the Committee Review Panel will be confidential and will not be transcribed. The Committee Review Panel will render a written decision within 5 working days of the conclusion of the Committee Review. For grievances, the written decision will contain: The specific factual basis for the decision stated in detail in clear, understandable language. A reference to the specific criteria and standards, including interpretive guidelines on which the grievance decision was based. The name, business address and business telephone number of the medical director who made the grievance decision. A statement that a list of individuals participating in the review of the dispute, along with their titles and credentials is available upon written request. A statement of the reviewer understands of the pertinent facts of the dispute. A reference to the evidence or documentation used as the basis for the decision. A statement advising the Member, the Member s Representative or the health care provider that they have the right to file a complaint with the Maryland Insurance Commissioner within 4 months after receipt of the grievance decision. The contact information for the Maryland Insurance Commissioner also will be provided. A statement advising the Member that the Health Advocacy Unit is available to assist the Member or the Member s Representative in filing a complaint with the Maryland Insurance Commissioner. The contact information for the Health Advocacy Unit also will be provided. -82-

83 Expedited Review of Adverse Decisions The Member, the Member s Representative or the health care provider on behalf of the Member, may request an expedited review when an adverse decision is rendered for health care services that are proposed but have not been delivered. The services must be necessary to treat a condition or illness that, without immediate medical attention, would: Seriously jeopardize the life or health of the Member or the Member s ability to regain maximum function; or Cause the Member to be a danger to him/herself or others. Aetna s Medical Director will determine whether an emergency exists. The Member, the Member s Representative and the health care provider will be notified immediately if Aetna does not have sufficient information to complete the expedited review and Aetna will help the Member, the Member s Representative or the health care provider in gathering the necessary information without further delay. Expedited reviews will be completed within 24 hours of the time the Member, the Member s Representative or the health care provider initiates the request. A Member may file a complaint with the Maryland Insurance Commissioner if the expedited review is not completed within 24 hours of the request. Within 1 day after a decision has been orally communicated to the Member, the Member s Representative or the health care provider, a written notice will be sent to the Member, the Member s Representative and the health care provider. The notice will include: The specific factual basis for the decision stated in detail in clear, understandable language. A reference to the specific criteria and standards (including interpretive guidelines) on which the expedited review was based. The name, business address and business telephone number of the medical director that performed the expedited review. A statement informing the Member, the Member s Representative or the health care provider on behalf of the Member, that they have the right to file a complaint with the Maryland Insurance Commissioner within 4 months of receipt of the grievance decision. The contact information for the Maryland Insurance Commissioner also will be provided. A statement advising the Member that the Health Advocacy Unit is available to assist the Member or the Member s Representative in filing a complaint with the Maryland Insurance Commissioner. The contact information for the Health Advocacy Unit also will be provided. If the expedited review is a concurrent review determination, the service should be continued without liability to the Member until the Member is notified of the decision. This does not apply if the service is related to an initial unauthorized admission. Expedited reviews for retrospective non-certifications are not required. -83-

84 Record Retention Records of all administrative complaints, complaints, appeals and grievances will be retained for a period of at least 10 years. Fees and Costs Nothing herein will be construed to require Aetna to pay counsel fees or any other fees or costs incurred by a Member in pursuing an appeal, grievance, complaint or administrative complaint. COORDINATION OF BENEFITS Definitions. When used in this provision, the following words and phrases have the following meaning: Allowable Expense A health care service or expense, including Deductibles, coinsurance and Copayments, that is covered at least in part by any of the Plans covering the Member. When a Plan provides benefits in the form of services the reasonable cash value of each service will be considered an Allowable Expense and a benefit paid. An expense or service that is not covered by any of the Plans is not an Allowable Expense. The following are examples of expenses and services that are not Allowable Expenses: If a Member is confined in a private Hospital room, the difference between the cost of a semiprivate room in the Hospital and the private room (unless the Member s stay in the private Hospital room is Medically Necessary in terms of generally accepted medical practice, or one of the Plans routinely provides coverage of Hospital private rooms) is not an Allowable Expense. If a Member is covered by 2 or more Plans that compute their benefit payments on the basis of Reasonable Charge, any amount in excess of the highest of the Reasonable Charges for a specific benefit is not an Allowable Expense. If a Member is covered by 2 or more Plans that provide benefits or services on the basis of negotiated fees, an amount in excess of the highest of the negotiated fees is not an Allowable Expense, unless the Secondary Plan s provider s contract prohibits any billing in excess of the provider s agreed upon rates. The amount a benefit is reduced by the Primary Plan because a Member does not comply with the Plan provisions. Examples of these provisions are second surgical opinions, precertification of admissions, and preferred provider arrangements. If a Member is covered by one Plan that calculates its benefits or services on the basis of Reasonable Charges and another Plan that provides its benefits or services on the basis of negotiated fees, the Primary Plan s payment arrangements shall be the Allowable Expense for all the Plans. However, if the provider has contracted with the secondary plan to provide the benefit or service for a specific negotiated fee or payment amount that is different than the primary plan s payment arrangement and if the provider s contract permits, that negotiated fee or payment shall be the allowable expense used by the secondary plan to determine its benefits. -84-

85 Claim Determination Period(s) Usually, the Plan Year. Closed Panel Plan(s) A Plan that provides health benefits to Members primarily in the form of services through a panel of Providers that have contracted with or are employed by the Plan, and that limits or excludes benefits for services provided by other Providers, except in cases of Emergency Services or Referral by a panel Provider. -85-

86 Coordination of Benefits (COB) A provision that is intended to avoid claims payment delays and duplication of benefits when a person is covered by 2 or more Plans. It avoids claims payment delays by establishing an order in which Plans pay their claims and providing the authority for the orderly transfer of information needed to pay claims promptly. It may avoid duplication of benefits by permitting a reduction of the benefits of a Plan when, by the rules established by this provision, it does not have to pay its benefits first. Custodial Parent A parent awarded custody by a court decree. In the absence of a court decree, it is the parent with whom the child resides more than one half of the Plan Year without regard to any temporary visitation. Medicare The health insurance provided by Title XVIII of the Social Security Act, as amended. It includes Aetna or similar coverage that is an authorized alternative to Parts A and B of Medicare. Plan(s) Any Plan providing benefits or services by reason of medical or dental care or treatment, which benefits or services are provided by one of the following: Group, blanket, or franchise health insurance policies issued by insurers, including health care service contractors; Other prepaid coverage under service plan contracts, or under group or individual practice; Uninsured arrangements of group or group-type coverage; Labor-management trusteed plans, labor organization plans, employer organization plans, or employee benefit organization plans; Medical benefits coverage in a group or group-type; Medicare or other governmental benefits; Other group-type contracts. Group type contracts are those which are not available to the general public and can be obtained and maintained only because membership in or connection with a particular organization or group. A Plan does not include: Hospital indemnity coverage benefits or other fixed indemnity coverage; Accident only coverage; Specified accident coverage; An individually underwritten and issued, guaranteed renewable, specified disease policy, or intensive care policy, which does not provide benefits on an expense-incurred basis; School accident-type coverages that cover students for accidents only, including athletic injuries, either on a twenty-four-hour basis or on a to and from school basis; Benefits provided in long-term care insurance policies for non-medical services, for example, personal care, adult day care, homemaker services, assistance with activities of daily living, respite care and custodial care or for contracts that pay a fixed daily benefit without regard to expenses incurred or the receipt of services; Medicare supplement policies; A state plan under Medicaid; or A governmental plan, which, by law, provides benefits that are in excess of those of any private insurance plan or other non-governmental plan. -86-

87 If the Plan includes both medical and dental coverage, those coverages will be considered separate Plans. The Medical/Pharmacy coverage will be coordinated with other Medical/Pharmacy Plans. In turn, the dental coverage will be coordinated with other dental Plans. If the contract includes both medical and dental coverage, those coverages will be considered 1 Plan. Plan Expenses Any necessary and reasonable health expenses, part or all of which are covered under this Plan. Primary Plan/Secondary Plan The order of benefit determination rules state whether coverage under this Certificate is a Primary Plan or Secondary Plan as to another Plan covering the Member. When coverage under this Certificate is a Primary Plan, its benefits are determined before those of the other Plan and without considering the other Plan s benefits. When coverage under this Certificate is a Secondary Plan, its benefits are determined after those of the other Plan and may be reduced because of the other Plan s benefits. When there are more than 2 Plans covering the person, coverage under this Certificate may be a Primary Plan as to 1 or more other Plans, and may be a Secondary Plan as to a different Plan(s). This Coordination of Benefits (COB) provision applies to this Certificate when a Subscriber or the Covered Dependent has medical and dental coverage under more than 1 Plan. The Order of Benefit Determination Rules below determines which Plan will pay as the Primary Plan. The Primary Plan pays first without regard to the possibility that another Plan may cover some expenses. A Secondary Plan pays after the Primary Plan and may reduce the benefits it pays. Order of Benefit Determination When 2 or more Plans pay benefits, the rules for determining the order of payment are as follows: The Primary Plan pays or provides its benefits as if the Secondary Plan(s) did not exist. A Plan that does not contain a COB provision that is consistent with this provision is always primary. There is one exception: coverage that is obtained by virtue of membership in a group that is designed to supplement a part of a basic package of benefits may provide that the supplementary coverage shall be excess to any other parts of the Plan provided by the Contract Holder. Examples of this type of exception are major medical coverage s that are superimposed over base plan providing Hospital and surgical benefits, and insurance type coverage s that are written in connection with a Closed Panel Plan to provide out-of-network benefits. A Plan may consider the benefits paid or provided by another Plan in determining its benefits only when it is secondary to that other Plan. -87-

88 The first of the following rules that describes which Plan pays its benefits before another Plan is the rule which will govern: Non-Dependent or Dependent. The Plan that covers the person other than as a dependent, for example as an employee, Subscriber or retiree is primary and the Plan that covers the person as a dependent is secondary. However, if the person is a Medicare beneficiary and, as a result of federal law, Medicare is secondary to the Plan covering the person as a dependent; and primary to the Plan covering the person as other than a dependent (e.g. a retired employee); then the order of benefits between the 2 Plans is reversed so that the Plan covering the person as an employee, Subscriber or retiree is secondary and the other Plan is primary. Dependent Child Covered Under More Than One Plan. The order of benefits when a child is covered by more than one Plan is: The Primary Plan is the Plan of the parent whose birthday is earlier in the year if: - The parents are married; - The parents are not separated (whether or not they ever have been married); or - A court decree awards joint custody without specifying that 1 party has the responsibility to provide health care coverage. If both parents have the same birthday, the Plan that covered either of the parents longer is primary. If the specific terms of a court decree state that one of the parents is responsible for the child s health care expenses or health care coverage and the Plan of that parent has actual knowledge of those terms, that Plan is primary. This rule applies to Claim Determination Periods or Plan Years commencing after the Plan is given notice of the court decree. If the parents are not living together, or are separated (whether or not they ever have been married) or are divorced, the order of benefits is: - The Plan of the Custodial Parent; - The Plan of the spouse of the Custodial Parent; - The Plan of the non-custodial parent; and then - The Plan of the spouse of the non-custodial parent. For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as described above as if those individuals were parents of the child. For a dependent child who has coverage under either or both parent s plans and also has his or her own coverage as a dependent under a spouse s plan, the Longer or Shorter Length of Coverage rule applies. In the event the dependent child s coverage under the spouse s plan began on the same date as the dependent child s coverage under either or both parents, the order of benefits shall be determined by applying the birthday rule to the dependent child s parent(s) and the dependent s spouse. -88-

89 Active or Inactive Employee. The Plan that covers a person as an employee who is neither laid off nor retired, is the Primary Plan. The same holds true if a person is a dependent of a person covered as a retiree and an employee. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule is ignored. Continuation Coverage. If a person whose coverage is provided under a right of continuation provided by federal or state law also is covered under another Plan, the Plan covering the person as an employee, Subscriber or retiree (or as that person s dependent) is primary, and the continuation coverage is secondary. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule is ignored. Longer or Shorter Length of Coverage. The Plan that covered the person longer is primary. If the preceding rules do not determine the Primary Plan, the Allowable Expenses shall be shared equally between the Plan s meeting the definition of Plan under this section. In addition, this Plan will not pay more than it would have paid had it been primary. Effect on Benefits of this Certificate When this Plan is secondary, it may reduce its benefits by the amount that makes the total benefits paid or provided by all Plans during a Claim Determination Period not more than 100% of total Allowable Expenses.. In addition, when this Plan is secondary, it will credit to the Plan deductible any amounts it would have credited to the deductible in the absence of other health care coverage. The difference between the benefit payments that this Plan would have paid had it been the Primary Plan, and the benefit payments that it actually paid or provided shall be recorded as a benefit reserve for the Member and used by this Plan to pay any Allowable Expenses, not otherwise paid during the claim determination period. As each claim is submitted, this Plan will: Determine its obligation to pay or provide benefits under its contract; Determine whether a benefit reserve has been recorded for the Member; and Determine whether there are any unpaid Allowable Expenses during that Claim Determination Period. If a Member is enrolled in 2 or more Closed Panel Plans and if, for any reason, including the provision of service by a non-panel provider, benefits are not payable by 1 Closed Panel Plan, COB shall not apply between that Plan and other Closed Panel Plans. Effect of Medicare The following provisions explain how the benefits under this Certificate interact with benefits available under Medicare. -89-

90 A Member is eligible for Medicare if Member: Is covered under Medicare by reason of age, disability, or End Stage Renal Disease; Is not covered under Medicare because of: - Having refused Medicare; - Having dropped Medicare; or - Having failed to make proper request for Medicare. This does not include the failure or refusal of the individual to apply for Medicare Part B. If a Member is eligible for Medicare, coverage under this Certificate will be determined as follows: If a Subscriber s coverage under this Certificate is based on current employment with the Contract Holder, coverage under this Certificate will act as the primary payor for the Medicare beneficiary who is eligible for Medicare: Solely due to age if this Plan is subject to the Social Security Act requirements for Medicare with respect to working aged (i.e., generally a plan of an employer with 20 or more employees); Due to diagnosis of End Stage Renal Disease, but only during the first 30 months of such eligibility for Medicare benefits. But this does not apply if at the start of such eligibility the Member was already eligible for Medicare benefits and this Plan s benefits were payable on a Secondary Plan basis; Solely due to any disability other than End Stage Renal Disease; but only if this Plan meets the definition of a large group health plan in the Internal Revenue Code (i.e., generally a plan of an employer with 100 or more employees). Otherwise, coverage under this Certificate will cover the benefits as the Secondary Plan. Coverage under this Certificate will pay the difference between the benefits of this Plan and the benefits that Medicare pays, up to 100% of Allowable Expenses. Charges used to satisfy a Member s Part B deductible under Medicare will be applied under this Plan in the order received by Aetna. Two or more charges received at the same time will be applied starting with the largest first. Any rule for coordinating other plan benefits with those under this Plan will be applied after this Plan s benefits have been figured under the above rules. Multiple Coverage Under this Plan If a Member is covered under this Plan both as a Subscriber and a Covered Dependent or as a Covered Dependent of 2 Subscribers, the following will also apply: The Members coverage in each capacity under this Plan will be set up as a separate Plan. The order in which various Plans will pay benefits will apply to the Plans set up above and to all other Plans. This provision will not apply more than once to figure the total benefits payable to the person for each claim under this Plan. -90-

91 Right to Receive and Release Needed Information Certain facts about health care coverage and services are needed to apply these COB rules and to determine benefits under this Plan and other Plans. Aetna has the right to release or obtain any information and make or recover any payments it considers necessary in order to administer this provision. Facility of Payment Any payment made under another Plan may include an amount which should have been paid under coverage under this Certificate. If so, Aetna may pay that amount to the organization, which made that payment. That amount will then be treated as though it were a benefit paid under this Certificate. Aetna will not have to pay that amount again. The term payment made means reasonable cash value of the benefits provided in the form of services. Right of Recovery If the amount of the payments made by Aetna is more than it should have paid under this COB provision, it may recover the excess from one or more of the persons it has paid or for whom it has paid; or any other person or organization that may be responsible for the benefits or services provided for the Member. The amount of the payments made includes the reasonable cash value of any benefits provided in the form of services. -91-

92 SUBROGATION AND RIGHT OF REIMBURSEMENT As used herein, the term Third Party means any party that is, or may be, or is claimed to be responsible for injuries or illness to a Member. Such injuries or illness are referred to as Third Party injuries. Responsible Party includes any parties actually, possibly or potentially responsible for payment of expenses associated with the care or treatment of Third Party injuries. If this Plan provides benefits under this Certificate to a Member for expenses incurred due to Third Party injuries, then Aetna retains the right to repayment to the extent any actual payments made by this Plan on behalf of the Member are the result of injury or illness that is caused by the Third Party. Aetna s rights of recovery apply to any recoveries made by or on behalf of the Member for those medical expenses recovered as result of a cause of action. Aetna s rights of recovery apply to: payments made by a Third Party or any insurance company on behalf of the Third Party; any payments or awards under an uninsured or underinsured motorist coverage policy; any Workers Compensation or disability award or settlement; premises or homeowners medical payments coverage or premises or homeowners insurance coverage; and any other payments from a source intended to compensate a Member for Third Party injuries. By accepting benefits under this Plan, the Member specifically acknowledges Aetna s right of subrogation. When this Plan provides health care benefits for expenses incurred due to Third Party injuries, Aetna shall be subrogated to the Member s rights of recovery against any party to the extent of the full cost of all benefits provided by this Plan. Aetna may proceed against any party with or without the Member s consent. By accepting benefits under this Plan, the Member also specifically acknowledges Aetna s right of reimbursement. This right of reimbursement attaches when this Plan has provided health care benefits for expenses incurred due to Third Party injuries and the Member or the Member s representative has recovered those medical expenses as a result of a cause of action, including but not limited to: payments made by a Third Party or any insurance company on behalf of the Third Party; any payments or awards under an uninsured or underinsured motorist coverage policy; any Workers Compensation or disability award or settlement; premises or homeowners medical payments coverage or premises or homeowners insurance coverage; and any other payments from a source intended to compensate a Member for Third Party injuries. By providing any benefit under Certificate, Aetna is granted an assignment of the proceeds of any settlement, judgment or other payment received by the Member to the extent of the full cost of all benefits provided by this Plan for the occurrence giving rise to the cause of action. Aetna s right of reimbursement is cumulative with and not exclusive of Aetna s subrogation right and Aetna may choose to exercise either or both rights of recovery. Aetna s right to reimbursement does not include recovery of any payments made to a Member under the personal injury protection coverage of a motor vehicle liability insurance policy. By accepting benefits under this Plan, the Member and the Member s representatives further agree to: Notify Aetna promptly and in writing when notice is given to any party of the intention to investigate or pursue a claim to recover damages or obtain compensation due to Third Party injuries sustained by the Member; Cooperate with Aetna, provide Aetna with requested information, and do whatever is necessary to secure Aetna's rights of subrogation and reimbursement under this Certificate; -92-

93 Give Aetna a first-priority lien on any recovery, settlement or judgment or other source of compensation which may be had from any party to the extent any actual payments made by the Plan result from the occurrence that gave rise to the cause of action for which the Third Party is or may be responsible. Aetna s lien only applies to compensation the Member receives as part of a recovery for medical expenses in a cause of action; and Pay, as the first priority, from any recovery, settlement, judgment, or other source of compensation, any and all amounts due Aetna as reimbursement to the extent any actual payments made by the Plan result from the occurrence that gave rise to cause of action unless otherwise agreed to by Aetna. Such payment is only from compensation the Member receives as part of a recovery for medical expenses in a cause of action; and Do nothing to prejudice Aetna's rights as set forth above. This includes, but is not limited to, refraining from making any settlement or recovery which specifically attempts to reduce or exclude the full cost of all benefits provided by this Plan. Serve as a constructive trustee for the benefit of this Plan over any settlement or recovery funds received as a result of Third Party injuries. Aetna may only recover the actual payments provided by this Plan under this Certificate without regard to any claim of fault on the part of the Member, whether by comparative negligence or otherwise. In no event will Aetna require a Member to repay more than the Member actually recovered from the third-party, less a pro-rata reduction for court costs and legal fees incurred by the Member to secure the recovery. -93-

94 RECOVERY RIGHTS RELATED TO WORKERS COMPENSATION If benefits are provided by Aetna for illness or injuries to a Member and Aetna determines the Member received Workers Compensation benefits for the same incident that resulted in the illness or injuries, Aetna has the right to recover as described under the Subrogation and Right of Recovery provision. Workers Compensation benefits includes benefits paid in connection with a Workers Compensation claim, whether paid by an employer directly, a workers compensation insurance carrier, or any fund designed to provide compensation for workers compensation claims. Aetna will exercise its Recovery Rights against the Member. The Recovery Rights will be applied even though: The Workers Compensation benefits are in dispute or are paid by means of settlement or compromise; No final determination is made that bodily injury or sickness was sustained in the course of or resulted from the Member s employment; The amount of Workers Compensation benefits due to medical or health care is not agreed upon or defined by the Member or the Workers Compensation carrier; or The medical or health care benefits are specifically excluded from the Workers Compensation settlement or compromise. By accepting benefits under this Plan, the Member or the Member s representatives agree to notify Aetna of any Workers Compensation claim made, and to reimburse Aetna as described above. -94-

95 RESPONSIBILITY OF MEMBERS Members or applicants shall complete and submit to Aetna such application or other forms or statements as Aetna may reasonably request. Members represent that all information contained in such applications, forms and statements submitted to Aetna incident to enrollment under this Certificate or the administration herein shall be true, correct, and complete to the best of the Member s knowledge and belief. The Member shall notify Aetna immediately of any change of address for the Member or any of the Subscriber s Covered Dependents, unless a different notification process is agreed to between Aetna and Contract Holder. The Member understands that Aetna is acting in reliance upon all information provided to it by the Member at time of enrollment and afterwards and represents that information so provided is true and accurate. By electing coverage pursuant to this Certificate, or accepting benefits hereunder, all Members who are legally capable of contracting, and the legal representatives of all Members who are incapable of contracting, at time of enrollment and afterwards, represent that all information so provided is true and accurate and agree to all terms, conditions and provisions in this Certificate. Members are subject to and shall abide by the rules and regulations of each Provider from which benefits are provided. -95-

96 GENERAL PROVISIONS Identification Card The identification card issued by Aetna to Members pursuant to this Certificate is for identification purposes only. Possession of an Aetna identification card confers no right to services or benefits under this Certificate. To be eligible for services or benefits under this Certificate, the holder of the card must be a Member on whose behalf all applicable Premium charges under this Certificate have been paid. Any person receiving services or benefits which such person is not entitled to receive pursuant to the provisions of this Certificate shall be charged for such services or benefits at billed charges. Reports and Records Aetna is entitled to receive from any Provider of services to Members, information reasonably necessary to administer this Certificate subject to all applicable confidentiality requirements as defined in the General Provisions section of this Certificate. By accepting coverage under this Certificate, the Subscriber, for himself or herself, and for all Covered Dependents covered hereunder, authorizes each and every Provider who renders services to a Member hereunder to: Disclose all facts pertaining to the care, treatment and physical condition of the Member to Aetna, or a medical, dental, or mental health professional that Aetna may engage to assist it in reviewing a treatment or claim; Render reports pertaining to the care, treatment and physical condition of the Member to Aetna, or a medical, dental, or mental health professional that Aetna may engage to assist it in reviewing a treatment or claim; and Permit copying of the Member s records by Aetna. Refusal of Treatment A Member may, for personal reasons, refuse to accept procedures, medicines, or courses of treatment recommended by a Participating Provider. If the Participating Provider (after a second Participating Provider s opinion, if requested by Member) believes that no professionally acceptable alternative exists, and if after being so advised, Member still refuses to follow the recommended treatment or procedure, neither the Participating Provider, nor Aetna, will have further responsibility to provide any of the benefits available under this Certificate for treatment of such condition. Aetna will provide written notice to Member of a decision not to provide further benefits for a particular condition. This decision is subject to the Administrative Complaint, Grievance And Appeal Procedure in this Certificate. Coverage for treatment of the condition involved will be resumed in the event Member agrees to follow the recommended treatment or procedure. Assignment of Benefits All rights of the Member to receive benefits hereunder are personal to the Member and may not be assigned. A Member s right to receive payment for benefits will be assigned to a Provider, unless the Member provides evidence that the Member has already paid the Provider. -96-

97 Legal Action No action at law or in equity may be maintained against Aetna for any expense or bill prior to the expiration of 60 days after written proof of loss has been furnished in accordance with requirements set forth in the Group Agreement No action shall be brought after the expiration of 3 years after the time written submission of claim is required to be furnished. Independent Contractor Relationship Participating Providers, non-participating Providers, institutions, facilities or agencies are neither agents nor employees of Aetna. Neither Aetna nor any Member of Aetna is an agent or employee of any Participating Provider, non-participating Provider, institution, facility or agency. Neither the Contract Holder nor a Member is the agent or representative of Aetna, its agents or employees, or an agent or representative of any Participating Provider or other person or organization with which Aetna has made or hereafter shall make arrangements for services under this Certificate. Participating Physicians maintain the physician-patient relationship with Members and are solely responsible to Member for all Medical Services which are rendered by Participating Physicians. Aetna cannot guarantee the continued participation of any Provider or facility with Aetna. In the event a PCP terminates its contract or is terminated by Aetna, Aetna shall provide notification to Members in the following manner: - Within 30 days of the termination of a PCP contract to each affected Subscriber, if the Subscriber or any Dependent of the Subscriber is currently enrolled in the PCP s office; and - Services rendered by a PCP or Hospital to an enrollee between the date of termination of the Provider Agreement and 5 business days after notification of the contract termination is mailed to the Member at the Member s last known address shall continue to be Covered Benefits. Restriction on Choice of Providers: Unless otherwise approved by Aetna, Members must utilize Participating Providers and facilities who have contracted with Aetna to provide services. Inability to Provide Service If due to circumstances not within the reasonable control of Aetna, including but not limited to, major disaster, epidemic, complete or partial destruction of facilities, riot, civil insurrection, disability of a significant part of the Participating Provider Network, the provision of medical or Hospital benefits or other services provided under this Certificate is delayed or rendered impractical,. Aetna shall be liable for reimbursement of the expenses necessarily incurred by any Member in procuring the services through other providers, to the extent prescribed by the Insurance Commissioner of Maryland. Aetna will make a good faith effort to provide or arrange for the provision of services, taking into account the impact of the event. -97-

98 Confidentiality Information contained in the medical records of Members and information received from any Provider incident to the provider-patient relationship shall be kept confidential in accordance with applicable law. Information may be used or disclosed by Aetna when necessary for a Member s care or treatment, the operation of Aetna and administration of this Certificate, or other activities, as permitted by applicable law. Members can obtain a copy of Aetna s Notice of Information Practices by calling the Member Services toll-free telephone number listed on the Member s identification card. Limitation on Services Except in cases of Emergency Services or Urgent Care, or as otherwise provided under this Certificate, services are available only from Participating Providers and Aetna shall have no liability or obligation whatsoever on account of any service or benefit sought or received by a Member from any Physician, Hospital, Skilled Nursing Facility, home health care agency, or other person, entity, institution or organization unless prior arrangements are made by Aetna. Incontestability In the absence of fraud: All statements made by a Member shall be considered representations and not warranties; No statement shall be the basis for voiding coverage or denying a claim after the Members coverage has been in force for 2 years; A statement made to effectuate coverage may not be used to avoid the coverage or reduce benefits unless (i) the statement is contained in a written instrument signed by the Contract Holder or Member, and (ii) a copy of the statement is given to the Contract Holder or Member. Additional Provisions The following additional provisions apply to your coverage: This Certificate applies to coverage only, and does not restrict a Member s ability to receive health care benefits that are not, or might not be, Covered Benefits. Contract Holder hereby makes Aetna coverage available to persons who are eligible under the Eligibility and Enrollment section of this Certificate. However, this Certificate shall be subject to amendment, modification or termination in accordance with any provision hereof, by operation of law, by filing with and approval by the Maryland Insurance Administration. This can also be done by mutual written agreement between Aetna and Contract Holder without the consent of Members. Aetna may adopt policies, procedures, rules and interpretations to promote orderly and efficient administration of this Certificate. No agent or other person, except an authorized representative of Aetna, has authority to waive any condition or restriction of this Certificate, to extend the time for making a payment, or to bind Aetna by making any promise or representation or by giving or receiving any information. -98-

99 No change in this Certificate shall be valid unless evidenced by an endorsement to it signed by an authorized representative of Aetna. This Certificate, including the Schedule of Benefits and any amendments, endorsements, inserts, or attachments, constitutes the entire Certificate between the parties hereto pertaining to the subject matter hereof and supersedes all prior and contemporaneous arrangements, understandings, negotiations and discussions of the parties with respect to the subject matter hereof, whether written or oral. There are no warranties, representations, or other agreements between the parties in connection with the subject matter hereof, except as specifically set forth in this Certificate. No supplement, modification or waiver of this Certificate shall be binding unless executed in writing by authorized representatives of the parties. This Certificate has been entered into and shall be construed according to applicable state and federal law. Proof of Loss and Claims Payment Proof of Loss: Written proof of loss must be furnished to Aetna within 180 days after a Member incurs expenses for Covered Benefits. Failure to furnish the proof of loss within the time required will not invalidate nor reduce any claim if it is not reasonably possible to give the proof of loss within 180 days, provided the proof of loss is furnished as soon as reasonably possible. However, except in the absence of legal capacity of the claimant, the proof of loss may not be furnished later than one year from the date when the proof of loss was originally required. A proof of loss form may be obtained from Aetna or the Contract Holder. If the Member does not receive such form before the expiration of 15 days from the date the Member makers their request, the Member shall be deemed to have complied with the requirements of this Certificate upon submitting within the time fixed in this Certificate written proof covering the occurrence, character and extent of the loss for which claim is made. Time for Payment of Claim: Benefits payable under this Certificate will be paid no more than 30 days after the receipt by Aetna of satisfactory proof of loss. If any portion of a claim is contested by Aetna, the uncontested portion of the claim will be paid no more than 30 days after the receipt of proof of loss by Aetna. Financial Sanctions Exclusions: If coverage provided under this certificate violates or will violate any economic or trade sanctions, the coverage is immediately considered invalid. For example, Aetna companies cannot make payments for health care or other claims or services if it violates a financial sanction regulation. This includes sanctions related to a blocked person or a country under sanction by the United States, unless it is permitted under a written license from the Office of Foreign Asset Control (OFAC). For more information visit

100 DEFINITIONS The following words and phrases when used in this Certificate shall have, unless the context clearly indicates otherwise, the meaning given to them below: Aetna Aetna Health Inc., is a Maryland corporation that was issued a certificate of authority by the Maryland Insurance Administration to operate as a Health Maintenance Organization. Ambulance A vehicle that is staffed with medical personnel and equipped to transport an ill or injured person. Behavioral Health Provider A licensed or certified organization or professional acting within the scope of their licenses or certifications, such as psychiatrists, psychologists, clinical social workers, licensed or certified professional counselors, or marriage and family therapists providing diagnostic, therapeutic or psychological services for behavioral health conditions. Biosimilar Prescription Drug(s) A biological Prescription Drug that is highly similar to a U.S. Food and Drug Administration (FDA) licensed reference biological Prescription Drug notwithstanding minor differences in clinically inactive components, and for which there are no clinically meaningful differences between the highly similar biological Prescription Drug and the reference biological Prescription Drug in terms of the safety, purity, and potency of the drug, as defined in accordance with U.S. Food and Drug Administration (FDA) regulations. Body Mass Index A practical marker that is used to assess the degree of obesity and is calculated by dividing the weight in kilograms by the height in meters squared. Brand-name Prescription Drug(s) Prescription drugs and insulin with a proprietary name assigned to it by the manufacturer or distributor and so indicated by MediSpan or any other similar publication designated by Aetna. Certificate This Certificate, including the Schedule of Benefits and any amendments, endorsements, inserts, or attachments, which outlines coverage for a Subscriber and Covered Dependents according to the Group Agreement. Contract Holder An employer or organization who agrees to remit the Premiums for coverage under the Group Agreement payable to Aetna. The Contract Holder shall act only as an agent of Aetna Members in the Contract Holder's group, and shall not be the agent of Aetna for any purpose

101 Copayment The specified dollar amount or percentage required to be paid by or on behalf of a Member in connection with benefits, if any, as set forth in the Schedule of Benefits. Cosmetic Services or supplies that alter, improve or enhance appearance. Cosmetic Surgery Any non-medically necessary surgery or procedure whose primary purpose is to improve or change the appearance of any portion of the body to improve self-esteem, but which does not restore bodily function, correct a diseased state, physical appearance, or disfigurement caused by an accident, birth defect, or correct or naturally improve a physiological function. Covered Dependent Any person in a Subscriber s family who meets all the eligibility requirements of the Eligibility and Enrollment section of this Certificate and has enrolled in Aetna. Covered Benefits Those Medically Necessary Services and supplies set forth in this Certificate, which are covered subject to all of the terms and conditions of the Group Agreement and this Certificate. Custodial Care Services and supplies that are primarily intended to help a Member meet their personal needs. Care can be Custodial Care even if it is prescribed by a Physician, delivered by trained medical personnel, or even if it involves artificial methods (or equipment) such as feeding tubes, monitors, or catheters. Examples of Custodial Care include, but are not limited to: Changing dressings and bandages, periodic turning and positioning in bed, administering oral medication, watching or protecting a Member. Care of a stable tracheostomy, including intermittent suctioning. Care of a stable colostomy/ileostomy. Care of stable gastrostomy/jejunostomy/nasogastric tube (intermittent or continuous) feedings. Care of a stable indwelling bladder catheter, including emptying/changing containers and clamping tubing. Respite care, adult (or child) day care, or convalescent care. Helping a Member perform an activity of daily living, such as: walking, grooming, bathing, dressing, getting in and out of bed, toileting, eating, or preparing food. Any services that an individual without medical or paramedical training can perform or be trained to perform. Deductible The first payments up to a specified dollar amount which a Member must make in the applicable Plan Year for Covered Benefits

102 Dentist A legally qualified Dentist or a Physician licensed to do the dental work he or she performs. Dental Provider This is: Any dentist; Group; Organization; Dental facility; or Other institution or person; that is legally qualified to furnish dental services or supplies. Detoxification The process whereby an alcohol or drug intoxicated or alcohol or drug dependent person is assisted, in a facility approved to provide detoxification services by the appropriate regulatory authority, through the period of time necessary to eliminate, by metabolic or other means, the intoxicating alcohol or drug, alcohol or drug dependent factors or alcohol in combination with drugs as determined by a licensed Physician, while keeping the physiological risk to the patient at a minimum. Durable Medical Equipment (DME) Equipment, as determined by Aetna, which is a) made for and mainly used in the treatment of a disease or injury; b) made to withstand prolonged use; c) suited for use while not confined as an inpatient in the Hospital; d) not normally of use to persons who do not have a disease or injury; e) not for use in altering air quality or temperature; and f) not for exercise or training. Effective Date of Coverage The commencement date of coverage under this Certificate as shown on the records of Aetna. Emergency Service Professional health services that are provided to treat a Medical Emergency. Services also include: A medical screening examination that is within the capability of the emergency department of a Hospital, including ancillary services routinely available to the emergency department to evaluate the Medical Emergency; and Further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities at the hospital. E-visit A telephone or internet-based consult with a Provider that has contracted with Aetna to offer these services

103 Experimental or Investigational Procedures Services or supplies that are, as determined by Aetna, experimental. Experimental means services that are not recognized as efficacious as the term is defined in the edition of the Institute of Medicine Report of Assessing Medical Technologies that is current when the care is rendered. Experimental services do not include controlled clinical trials. Generic Prescription Drug(s) Prescription drugs and insulin, whether identified by its chemical, proprietary, or non-proprietary name, that is accepted by the U.S. Food and Drug Administration as therapeutically equivalent and interchangeable with drugs having an identical amount of the same active ingredient and so indicated by MediSpan or any other similar publication designated by Aetna. Group Agreement The Group Agreement between Aetna and the Contract Holder, including the Group Application, this Certificate, including the Schedule of Benefits and any amendments, endorsements, inserts, or attachments, as subsequently amended by operation of law and as filed with and approved by the applicable public authority. Health Professional(s) A Physician or other professional who is properly licensed or certified to provide medical care under the laws of the state where the individual practices, and who provides Medical Services which are within the scope of the individual s license or certificate. Homebound Member A Member who is confined to their place of residence due to an illness or injury which makes leaving the home medically contraindicated or if the act of transport would be a serious risk to their life or health. Examples where a Member would not be considered homebound are: A Member who does not often travel from home because of feebleness and/or insecurity brought on by advanced age (or otherwise). A wheelchair bound Member who could safely be transported via wheelchair accessible transport. Home Health Services Those items and services provided by Participating Providers for the continued care and treatment of a Member in the home if: The institutionalization of the Member in a Hospital or related institution or Skilled Nursing Facility would otherwise have been required if home health care were not provided. The plan of treatment covering the home health services is established and approved in writing by the Participating Provider. Hospice Care A program of care that is provided by a Hospital, Skilled Nursing Facility, hospice, or a duly licensed Hospice Care agency, and is approved by Aetna, and is focused on a palliative rather than curative treatment for Members who have a medical condition and a prognosis of less than 12 months to live

104 Hospital(s) An institution rendering inpatient and outpatient services, accredited as a Hospital by the Joint Commission on Accreditation of Health Care Organizations, the Bureau of Hospitals of the American Osteopathic Association, or as otherwise determined by Aetna as meeting reasonable standards. A Hospital may be a general, acute care, rehabilitation or specialty institution. Infertile or Infertility A disease defined by the failure to conceive a pregnancy after 12 months or more of timed intercourse or egg-sperm contact for women under age 35 (or 6 months for women age 35 or older). Institute of Excellence TM (IOE) One of a network of facilities specifically contracted with by Aetna to provide certain Transplants to Members. A facility is considered a Participating Provider only for those types of Transplants for which it has been specifically contracted. L.P.N. A licensed practical or vocational nurse. Mail Order Pharmacy An establishment where prescription drugs are legally given out by mail or other carrier. Mastectomy The surgical removal of all or part of a breast. Medical Community A majority of Physicians who are Board Certified in the appropriate specialty. Medical Emergency The existence of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (ii) serious impairment to bodily functions; or (iii) serious dysfunction of any bodily organ or part. Medical Services The professional services of Health Professionals, including medical, surgical, diagnostic, therapeutic, preventive care and birthing facility services

105 Medically Necessary, Medically Necessary Services, or Medical Necessity These are health care or dental services that we determine a Physician, other health care provider or Dental Provider, exercising prudent clinical judgment, would give to a patient for the purpose of: preventing; evaluating; diagnosing; or treating: an Illness; an Injury; a disease; or its symptoms. The provision of the service, supply or Prescription Drug must, as we determine, be: In accordance with generally accepted standards of medical or dental practice; Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's Illness, Injury or disease; and Not mostly for the convenience of the patient, Physician, other health care or Dental Provider; and And do not cost more than an alternative service or sequence of services at least as likely to produce the same therapeutic or diagnostic results as to the diagnosis or treatment of that patient's Illness, Injury, or disease. Generally accepted standards of medical or dental practice means: Standards that are based on credible scientific evidence published in peer-reviewed medical literature. They must be generally recognized by the relevant medical or dental community; Standards set forth in policy issues involving clinical judgment Member(s) A Subscriber or Covered Dependent as defined in this Certificate. Mental Disorders This is an illness commonly understood to be a Mental Disorder, whether or not it has a physiological basis, and for which treatment is generally provided by or under the direction of a Behavioral Health Provider such as a Psychiatrist, a psychologist or a psychiatric social worker. The following conditions are considered a Mental Disorder under this plan: Anorexia/Bulimia Nervosa. Bipolar disorder. Major depressive disorder. Obsessive compulsive disorder. Panic disorder. Pervasive Mental Developmental Disorder (including Autism). Psychotic Disorders/Delusional Disorder. Schizo-affective Disorder. Schizophrenia. Also included is any other mental condition which requires Medically Necessary treatment

106 Morbid Obesity A Body Mass Index that is: greater than 40 kilograms per meter squared; or equal to or greater than 35 kilograms per meter squared with a comorbid medical condition, including cardiovascular disease, hypertension, sleep apnea, or uncontrolled type-2 diabetes. National Medical Excellence Program Coordinating Aetna services team for Transplant services and other specialized care. Negotiated Charge As to Health Coverage, (other than Prescription Drug Coverage): The Negotiated Charge is the maximum charge a Participating Provider has agreed to make as to any service or supply for the purpose of the benefits under this plan. As to Prescription Drug Coverage: The Negotiated Charge is the amount Aetna has established for each Prescription Drug obtained from a Participating Pharmacy under this plan. This Negotiated Charge may reflect amounts Aetna has agreed to pay directly to the Participating Pharmacy or to a third party vendor for the Prescription Drug, and may include an additional service or risk charge set by Aetna. The Negotiated Charge does not include or reflect any amount Aetna, an affiliate, or a third party vendor, may receive under a rebate arrangement between Aetna, an affiliate or a third party vendor and a drug manufacturer for any Prescription Drug, including Prescription Drugs on the Preferred Drug Guide (Formulary). Based on its overall drug purchasing, Aetna may receive rebates from the manufacturers of Prescription Drugs and may receive or pay additional amounts from or to third parties under price guarantees. These amounts will not change the Negotiated Charge under this plan. Network Pharmacy Is a retail Pharmacy, mail order Pharmacy or Specialty Network Pharmacy that has entered into a contractual agreement with Aetna, an affiliate, or a third party vendor, to furnish services and supplies for this plan. The appropriate Pharmacy type may also be substituted for the word Pharmacy. (E.g. retail Network Pharmacy, mail order Network Pharmacy or Specialty Network Pharmacy). Non-Hospital Facility A facility, licensed or certified by the appropriate regulatory authority, for the care or treatment of persons with mental disorders or alcohol or drug dependence, except for transitional living facilities. Non-Participating Providers These are Providers that are not Participating Providers. Non-Physician Specialist A health care provider who: Is not a physician; Is licensed or certified under the Health Occupations Article; and Is certified or trained to treat or provide health care services for a specified condition or disease in a manner that is within the scope of their license or certification

107 Non-Preferred Drug (Non-Formulary) This is a Prescription Drug or device that is not listed in the Preferred Drug Guide (Formulary). Open Enrollment Period A period each Plan Year, when eligible enrollees of the Contract Holder may enroll in Aetna without a waiting period or exclusion or limitation based on health status or, if already enrolled in Aetna, may transfer to an alternative health plan offered by the Contract Holder. Orthodontic Treatment This is any: Medical service or supply; or Dental service or supply; furnished to prevent or to diagnose or to correct a misalignment: Of the teeth; or Of the bite; or Of the jaws or jaw joint relationship; whether or not for the purpose of relieving pain. The following are not considered orthodontic treatment: The installation of a space maintainer; or A surgical procedure to correct malocclusion. Partial Hospitalization The provision of medical, nursing, counseling or therapeutic services on a planned and regularly scheduled basis in a Hospital or Non-Hospital Facility which is equipped and approved as an alcohol or drug abuse or mental illness treatment program by the appropriate regulatory authority to provide such services, and which is designed for a patient or client who would benefit from more intensive services than are offered in outpatient treatment but who does not require inpatient care. Participating A description of a Provider that has entered into a contractual agreement with Aetna for the provision of services to Members. Participating Dental Provider A Dental Provider that has entered into a contractual agreement with Aetna or an affiliate for the provision of services to you. Participating Dentist A Dentist that has entered into a contractual agreement with Aetna or an affiliate for the provision of services to you. Participating Infertility Specialist A Specialist who has entered into a contractual agreement with Aetna for the provision of Infertility services to Members

108 Physician(s) A duly licensed member of a medical profession, who has an M.D. or D.O. degree, who is properly licensed or certified to provide medical care under the laws of the state where the individual practices, and who provides Medical Services which are within the scope of the individual s license or certificate. Plan Year A period of 1 year commencing on the Contract Holder s Effective Date of Coverage and ending at 12:00 midnight on the last day of the 1 year period. Premium(s) The amount the Contract Holder or Member is required to pay to Aetna to continue coverage. Preferred Drug A Prescription Drug or device that is listed on the Preferred Drug Guide (Formulary). Preferred Drug Guide (Formulary) A listing of Prescription Drugs established by Aetna or an affiliate, which does not cover all Prescription Drugs. This list is subject to periodic review and modification by Aetna or an affiliate. A copy of the Preferred Drug Guide (Formulary) will be available upon your request or may be accessed on Aetna website at Premium Period The premium period is the span of time which begins at either the1st or 15 th of the month based on your Effective Date and ends 30 days later. Prescriber Any physician or dentist, acting within the scope of his or her license, who has the legal authority to write an order for a prescription drug. Prescription As to Prescription Drugs: A written order for the dispensing of a Prescription Drug by a Provider. If it is a verbal order, it must promptly be put in writing by the Pharmacy. As to vision care: A written order for the dispensing of Prescription lenses or Prescription contact lenses by an ophthalmologist or optometrist. Prescription Drug A drug, biological, or compounded Prescription which, by State and Federal Law, may be dispensed only by Prescription. This includes: Insulin; and An injectable drug prescribed to be self-administered or administered by any other person except one who is acting within his or her capacity as a paid healthcare professional

109 Primary Care Physician (PCP) A Participating Physician who supervises, coordinates and provides initial care and basic Medical Services as a general or family care practitioner, an internist or a pediatrician, or in some cases as an obstetrician/gynecologist to Members, initiates their Referral for Specialist care, and maintains continuity of patient care. Pediatricians include allopathic or osteopathic pediatricians. Provider(s) A Physician, Health Professional, Hospital, Skilled Nursing Facility, home health agency or other recognized entity or person licensed to provide Hospital or Medical Services to Members. Psychiatric Physician This is a physician who: Specializes in psychiatry; or Has the training or experience to do the required evaluation and treatment of Substance Abuse or Mental Disorders. Psychiatrist This is a Physician who: Specializes in psychiatry; or Has the training or experience to do the required evaluation and treatment of Substance Abuse or Mental Disorders. Qualified Medical Support Order An order that creates or recognizes the right of a child to receive benefits under a parent s health insurance coverage that is issued by: A court of this State or another state or territory; An administrative agency of another state or territory. Reconstructive Breast Surgery Surgery performed as a result of a Mastectomy to reestablish symmetry between the two breasts. Includes augmentation mammoplasty, reduction mammoplasty and mastopexy. Referral Specific directions or instructions from a Member s PCP, in conformance with Aetna s policies and procedures, that direct a Member to a Participating Provider for Medically Necessary care

110 Residential Treatment Facility (Mental Disorders) This is an institution that must: Meet all applicable licensing standards established by the jurisdiction in which it is located; Perform a comprehensive patient assessment preferably before admission, but at least upon admission; Create individualized active treatment plans directed toward the alleviation of the impairment that caused the admission; Have the ability to involve family and/or support systems in the therapeutic process; Have the level of skilled intervention and provision of care that is consistent with the patient s illness and risk; Provide access to psychiatric care by a Psychiatrist as Medically Necessary for the provision of such care; Provide treatment services that are managed by a Behavioral Health Provider who functions under the direction/supervision of a medical director; and Not be a Wilderness Treatment Program or any such related or similar program, school and/or education service. In addition to the above requirements, for Mental Health Residential Treatment Programs: A Behavioral Health Provider must be actively on duty 24 hours per day for 7 days a week; The patient must be treated by a Psychiatrist at least once per week; and The medical director must be a Psychiatrist. Residential Treatment Facility (Substance Abuse) This is an institution that must: Meet all applicable licensing standards established by the jurisdiction in which it is located; Perform a comprehensive patient assessment preferably before admission, but at least upon admission; Create individualized active treatment plans directed toward the alleviation of the impairment that caused the admission; Have the ability to involve family and/or support systems in the therapeutic process; Have the level of skilled intervention and provision of care that is consistent with the patient s illness and risk; Provide access to psychiatric care by a Psychiatrist as Medically Necessary for the provision of such care; Provide treatment services that are managed by a Behavioral Health Provider who functions under the direction/supervision of a medical director; and Not be a Wilderness Treatment Program or any such related or similar program, school and/or education service. In addition to the above requirements, for Chemical Dependence Residential Treatment Programs: A Behavioral Health Provider or an appropriately state certified professional (CADC, CAC, etc.), must be actively on duty during the day and evening therapeutic programming; and The medical director must be a Physician who is an addiction Specialist. In addition to the above requirements, for Chemical Dependence Detoxification Programs within a residential setting: An Registered Nurse (R.N.) must be onsite 24 hours per day for 7 days a week; and The care must be provided under the direct supervision of a Physician

111 Respite Care Care furnished during a period of time when the Member's family or usual caretaker cannot, or will not, attend to the Member's needs. Self-injectable Drug(s) Prescription drugs that are intended to be self administered by injection to a specific part of the body to treat certain chronic medical conditions. Service Area The geographic area established by Aetna and approved by the appropriate regulatory authority. Skilled Care Medical care that requires the skills of technical or professional personnel. Skilled Nursing Services that require the medical training of and are provided by a licensed nursing professional and are not Custodial Care. Skilled Nursing Facility An institution or a distinct part of an institution that is licensed or approved under state or local law, and which is primarily engaged in providing Skilled Nursing care and related services for residents who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons. Skilled Nursing Facility does not include institutions which provide only minimal care, Custodial Care services, ambulatory or part-time care services, or institutions which primarily provide for the care and treatment of Mental Disorder and Substance Abuse. The facility must qualify as a Skilled Nursing Facility under Medicare or as an institution accredited by the Joint Commission on Accreditation of Health Care Organizations, the Bureau of Hospitals of the American Osteopathic Association, the Commission on the Accreditation of Rehabilitative Facilities, or as otherwise determined by the health insurer to meet the reasonable standards applied by any of the aforesaid authorities. Examples of Skilled Nursing Facilities include Rehabilitation Hospitals (all levels of care, e.g. acute) and portions of a Hospital designated for Skilled or Rehabilitation services. Specialist(s) A Physician who provides medical care in any generally accepted medical or surgical specialty or subspecialty. Specialty Care Health care services or supplies that require the services of a specialist. Specialty Care Prescription Drugs Specialty care prescription drugs are drugs that cost $600 or more for up to a 30-day supply, require special handling, special storage or monitoring and include but are not limited to oral, topical, inhaled and injected routes of administration. You can access the list of specialty care prescription drugs and biosimilar prescription drugs by contacting Member Services by logging on to your Aetna Navigator secure member website at or calling the number on the back of your ID card

112 Specialty Network Pharmacy A network of pharmacies designated to fill Prescriptions for Self-injectable Drugs and Specialty Care Prescription Drugs. Subscriber A person who meets all applicable eligibility requirements as described in this Certificate and has enrolled in Aetna. Substance Abuse Any use of alcohol and/or drugs which produces a pattern of pathological use causing impairment in social or occupational functioning or which produces physiological dependency evidenced by physical tolerance or withdrawal. Substance Abuse Rehabilitation Services, procedures and interventions to eliminate dependence on or abuse of legal and/or illegal chemical substances, according to individualized treatment plans. Surgery or Surgical Procedure The diagnosis and treatment of injury, deformity and disease by manual and instrumental means, such as cutting, abrading, suturing, destruction, ablation, removal, lasering, introduction of a catheter (e.g., heart or bladder catheterization) or scope (e.g., colonoscopy or other types of endoscopy), correction of fracture, reduction of dislocation, application of plaster casts, injection into a joint, injection of sclerosing solution, or otherwise physically changing body tissues and organs. Telemedicine A telephone or internet-based consult with a Provider that has contracted with Aetna to offer these services. Therapeutic Drug Class A group of drugs or medications that have a similar or identical mode of action or exhibit similar or identical outcomes for the treatment of a disease or injury. Tier 1A A group of medications determined by us that may be available at a reduced copayment/coinsurance and are noted in the Preferred Drug Guide (Formulary) on the Aetna website at Tier 1 A group of medications determined by us that may be available at a reduced copayment/coinsurance and are noted on the Preferred Drug Guide (Formulary) on the Aetna website at

113 Totally Disabled or Total Disability A Member shall be considered Totally Disabled if: The Member is a Subscriber and is prevented, because of injury or disease, from performing any occupation for which the Member is reasonably fitted by training, experience, and accomplishments; or The Member is a Covered Dependent and is prevented because of injury or disease, from engaging in substantially all of the normal activities of a person of like age and sex in good health. Transplant Replacement of solid organs and non-solid organs. Transplant Occurrence Considered to begin at the point of authorization for evaluation for a Transplant, and end: (1) 30 days from the date of the Transplant; or (2) upon the date the Member is discharged from the Hospital or outpatient facility for the admission or visit(s) related to the Transplant, whichever is later provided, however, that a re-transplant of same organ type within 180 days of the first Transplant will be considered one Transplant Occurrence. Urgent Care Non-preventive or non-routine health care services which are Covered Benefits and are required in order to prevent serious deterioration of a Member s health following an unforeseen illness, injury or condition if: (a) the Member is temporarily absent from Aetna Service Area and receipt of the health care service cannot be delayed until the Member returns to Aetna Service Area; or, (b) the Member is within Aetna Service Area and receipt of the health care services cannot be delayed until the Member s Primary Care Physician is reasonably available. Urgent Care Facility This is: A facility licensed as a free-standing medical facility by applicable state and federal laws to treat an urgent condition. Walk-in Clinic A Participating free-standing health care facility. Neither of the following should be considered a Walk-in Clinic: An emergency room; nor The outpatient department of a Hospital

114 Health Maintenance Organization (HMO) Plan Schedule of Benefits If this is an ERISA plan, Members have certain rights under this plan. If the Contract Holder is a church group or a government group this may not apply. Please contact the Contract Holder for additional information. Underwritten by Aetna Health Inc. in the state of Maryland *See How to read the Schedule of Benefits and Important note about Member cost sharing at the beginning of this Schedule of Benefits HI SG-OFF2016-SB MD SG-off MD Gold HMO % 2016