Aetna Avenue Your Destination for Small Business Solutions

Transcription

1 Aetna Avenue Your Destination for Small Business Solutions Connecticut PLAN GUIDE Plans effective OCTOBER 1, 2010 For businesses with 1-50 eligible employees CT (6/10)

2 CT (6/10) C o n n e c t i c u t p l a n G U I D E Health care is a journey Aetna Avenue is the way I n this guide : 2 Small business commitment 3 Benefits for every stage of life 4 Medical overview 6 Managing health care expenses 8 Medical plan options 18 Dental overview 20 Dental plan options 28 Life & disability overview 30 Life & disability plan options 32 Underwriting guidelines 36 Product specifications 44 Limitations and exclusions As a small business owner, providing value to your customers and growing your business are your top priorities. Yet, today health care is a business issue for every entrepreneur. Small businesses need health insurance benefits plans that fit their workplace. Aetna Avenue provides employers with a choice of insurance benefits solutions. We know that choice, ease and reputation are as valuable to employers as they are to employees. Aetna offers a variety of plans for small business from medical plans, to dental, life and disability plans. Health benefits and health insurance, dental benefits/dental insurance, life insurance and disability insurance plans/policies are offered, underwritten or administered by Aetna Health Inc. and/or Aetna Life Insurance Company (Aetna).

3 C HOICE E a se Reputat i on For business owners and employees At Aetna, we provide employers a choice of health insurance benefits plans. Within these benefits programs, employers can choose specific plan designs that fit business and employee needs. And, employees have access to a wide network of doctors and other providers ensuring that they have a choice in how they receive their health care. Allowing you to focus on your business Employers want to focus on their customers and growing their business not the health insurance benefits program. Aetna makes sure that our plan designs are easy to set-up, administer, use and provide support to ensure your success. In business it s everything Your reputation is important to your business. At Aetna, our reputation is just as important. With 150 years of experience, we value our name, products and services and focus on delivering the right solution for your small business our reputation depends upon it CT (6/10) Medical plans supporting members on their health care journey HSA-compatible plans Inpatient Hospital/Outpatient Surgery Deductible plans Deductible/Coinsurance plans Dental, life and disability plans providing valuable protection DMO PPO PPO Max Freedom-of-Choice plan design Voluntary Basic term life insurance Disability plans Packaged life and disability plans Administration making it work for your business Aetna s plan designs automatically process health claim reimbursements, provide a password-protected website to keep track of accounts and are supported by knowledgeable service representatives. Secure and online, Aetna Enroll SM makes managing health benefits easy and eliminates time-consuming, expensive paper-based processes. Aetna Navigator our online resource for employers, members and providers Look up rates for providers, facilities and hospitals for common services and treatments Track medical claims online Discount programs for eye, dental and other health care Personal Health Record providing a complete picture of health Temporary ID cards available for members to print as needed Simple Steps To A Healthier Life, an online health and wellness program Our account executives, underwriters and customer service representatives are committed to providing your small business the valuable service it deserves. 1

4 C o n n e c t i c u t p l a n G U I D E Aetna Avenue s commitment to small business employers We know that small business owners health insurance benefits needs are often different than a larger employer. Aetna Avenue focuses on employers with 1-50 employees and our insurance benefits programs are designed to work for this size group. We ll work with you to determine the right plans for your business and assist you through implementation. Aetna s market map Guiding your small business health care journey Aetna s market map is a resource for brokers and employers to help determine the right insurance benefits plan for their business. The market map asks specific questions related to the business and employee need in order to narrow the field of plan design choices. Basic benefits for your employees Limiting the expense to your business Allowing employees to buy-up and share more of the cost You might be a Basic buyer These plans fit OA QPOS 8-10/10 OA QPOS 12-10/10 Do you value Employee responsibility Consumerism s ability to make a difference Tools and resources to support consumerism Innovative plan design You might be a Value seeker These plans fit OA QPOS Ap-10/10 HSA Compatible OA QPOS D-10/10 HSA Compatible OA QPOS F-10/10 HSA Compatible Traditional benefits plans Limiting the financial impact on employees You might be a Traditionalist These plans fit OA QPOS 6-10/10 OA QPOS 7-10/10 2

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

6 C o n n e c t i c u t p l a n G U I D E Aetna Avenue Medic al Overv iew Provider network All medical plans are available in the following counties : Wellness On Us S M Wellness for employees means a healthier business for employers. Our small business plans in Connecticut offer $0 copays for in-network eye exams on top of $0 copay for in-network preventive care! It s one more way for us to help employees get a step closer to better health. Fairfield New Haven Preventive care benefits: Hartford Litchfield Middlesex New London Tolland Windham Immunizations Routine adult physicals Well-child exams $0 copay $0 copay $0 copay Routine mammogram $0 copay Routine gyn exams $0 copay Routine vision exams (including refraction) $0 copay Routine DRE, routine PSA and routine colorectal cancer screening $0 copay 4

7 M E D I C A L Product Name Product Description PCP Required Referrals Required Aetna Open Access Quality Point-of-Service (OA QPOS) Aetna Open Access Managed Choice (OA MC) Traditional Choice (TC) Aetna Quality Point-of-Service (QPOS) is a two-tiered product that allows members to access care in or out of network. Members have lower out-of-pocket costs when they use the in-network tier of the plan. Member cost sharing increases if members decide to go out of network. Members may go to their PCP or directly to a participating specialist without a referral. It is their choice, each time they seek care. Managed Choice members can access any recognized provider for covered services without a referral. Each time members seek health care, they have the freedom to choose either network providers at lower out-of-pocket costs, or non-network providers at higher out-of-pocket costs. This indemnity plan option is available for employees who live outside the plan s network service area. Members coordinate their own health care and may access any recognized provider for covered services without a referral. Network Optional No Aetna Choice POS (Open Access) Optional No Managed Choice POS (Open Access) No No N/A AETNA OPEN ACC ESS QPOS, AETNA OPEN ACC ESS MANAGED CHOICE AND TR ADITIONAL CHOICE HSA COMPAT IBLE PL ANS The OA QPOS, OA Managed Choice and Traditional Choice insurance plans are compatible with a Health Savings Account (HSA). It is completely at the discretion of the employer or employee whether or not to establish an HSA. Should an employer or their qualified employee(s) decide to establish an HSA, they may be eligible for an affordable tax-advantaged solution that allows them to better manage their qualified medical and dental expenses. See page 6 for more details on the Aetna HealthFund Health Savings Account. 5

8 C o n n e c t i c u t p l a n G U I D E Aetna Avenue Medic al Overv iew Administrative fees FEE DESCRIPTION HSA FEE Initial Set-Up $0 Monthly Fees $0 POP* Initial Set-Up** $150 Renewal $75 HRA and FSA*** Initial Set-Up* 2-25 Employees $ Employees $450 Renewal Fee 50% of the initial set-up fee Monthly Fees Additional Set-Up Fee for stacked plans (those electing an Aetna HRA and FSA simultaneously) Participation Fee for stacked participants $5 per participant $150 $9.75 per participant Minimum Fees 0-25 Employees $10 per month minimum Employees $50 per month minimum TRA Annual Fee $350 Transit Monthly Fees Parking Monthly Fees COBRA Annual Fee Employees Monthly Fee $4.25 per participant $3.15 per participant $50 $0.85 per employee He alth Sav i ngs Account ( HSA) No set-up or administrative fees The Aetna HealthFund HSA, when coupled with a HSA-compatible high-deductible health benefits and health insurance plan, is a tax-advantaged savings account. Once enrolled, account contributions can be made by the employee and/or employer. The HSA can be used to pay for qualified expenses tax free. MEMBER S HSA Pl an H S A A c c o u n t You own your HSA Contribute tax free You choose how and when to use your dollars Roll it over each year and let it grow Earns interest, tax free T o d ay Use for qualified expenses with tax free dollars F u t u r e Plan for future and retiree health-related costs H i g h - d e d u c t i b l e h e a lt h p l a n Eligible in-network preventive care services will not be subject to the deductible You pay 100% until deductible is met, then only pay a share of the cost Meet out-of-pocket maximum, then plan pays 100% * First year POP fees waived with the purchase of medical with 5-plus enrolled employees. ** Non-discrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle testing available at employer request for $75 fee. Non-discrimination testing only available for FSA and POP products. *** Aetna FSA pricing is inclusive for POP. Debit cards are available for FSA only. Contact Aetna for further information. For HRA, if the employer opts out of Streamline, the fee is increased $1.50 per participant. Aetna HealthFund HRAs are subject to employer-defined use and forfeiture rules, and are unfunded liabilities of your employer. Fund balances are not vested benefits. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information is subject to change. Aetna reserves the right to change any of the above fees and to impose additional fees upon prior written notice. 6

9 M E D I C A L Health Reimbursement Arrangement (HRA) The Aetna HealthFund HRA combines the protection of a deductible-based health plan with a health fund that pays for eligible health care services. The member cannot contribute to the HRA, and employers have control over HRA plan designs and fund rollover. The fund is available to an employee for qualified expenses on the plan s effective date. The HRA and the HSA provide members with financial support for higher outof-pocket health care expenses. Aetna s consumer-directed health products and services give members the information and resources they need to help make informed health care decisions for themselves and their families while helping lower employers costs. COBR A administr at i on Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes that can assist employers with managing the complex billing and notification processes that are required for COBRA compliance, while also helping to save them time and money. Section 125 Cafeteria Plans and Section 132 Transit Reimbursement Accounts Employees can reduce their taxable income, and employers can pay less in payroll taxes. There are three ways to save: Premium Only Plans (POP) Employees can pay for their portion of the group health insurance expenses on a pretax basis. First-year POP fees waived with the purchase of medical with 5-plus enrolled employees. Flexible Savings Account (FSA) FSAs give employees a chance to save for health expenses with pretax money. Health Care Spending Accounts allow employees to set aside pretax dollars to pay for out-of-pocket expenses as defined by the IRS. Dependent Care Spending Accounts allow participants to use pretax dollars to pay child or elder care expenses. Transit Reimbursement Account (TRA) TRAs allow participants to use pretax dollars to pay transportation and parking expenses for the purpose of commuting to and from work. 7

10 C o n n e c t i c u t p l a n G U I D E A E T N A O P E N AC C E S S Q P O S H S A C O M PAT I B L E P L A N O P T I O N S * PLAN OPTIONS OA QPOS Ap-10/10 HSA Compatible OA QPOS Ac-10/10 HSA Compatible MEMBER BENEFITS In-Network Out-of-Network In-Network Out-of-Network Plan Coinsurance 0% after deductible 30% after deductible 0% after deductible 30% after deductible Plan/Calendar Year Deductible o $2,500 Single $5,000 Family $5,000 Single $10,000 Family $2,500 Single $5,000 Family $5,000 Single $10,000 Family Plan/Calendar Year Out-of-Pocket Maximum o $4,000 Single $8,000 Family $8,000 Single $16,000 Family $4,000 Single $8,000 Family $8,000 Single $16,000 Family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Primary Physician Office Visit $10 copay after deductible 30% after deductible $10 copay after deductible 30% after deductible Specialist Office Visit $25 copay after deductible 30% after deductible $25 copay after deductible 30% after deductible Wellness on Us SM Well-Child Exams, Immunizations, Routine GYN Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply) $0 copay; deductible waived 30% after deductible $0 copay; deductible waived 30% after deductible Adult Physicals (Age and frequency schedules apply) $0 copay; deductible waived Not Covered $0 copay; deductible waived Not Covered Aetna Vision SM Discount Program Included Not Covered Included Not Covered Outpatient Services Lab 0% after deductible 30% after deductible 0% after deductible 30% after deductible X-Ray $25 copay after deductible 30% after deductible $25 copay after deductible 30% after deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Inpatient Hospital Outpatient Surgery Outpatient Hospital Department Freestanding Surgical Facility Emergency Room (Copay waived if admitted) $75 copay per test after deductible up to a combined maximum of $375 per calendar year $250 copay per day up to a maximum of $1,000 per admission after deductible $250 copay after deductible $125 copay after deductible $150 copay after deductible 30% after deductible $75 copay per test after deductible up to a combined maximum of $375 per calendar year 30% after deductible $250 copay per day up to a maximum of $1,000 per admission after deductible 30% after deductible $250 copay after deductible 30% after deductible $125 copay after deductible Paid as In-Network $150 copay after deductible 30% after deductible 30% after deductible 30% after deductible 30% after deductible Paid as In-Network Urgent Care $75 copay after deductible 30% after deductible $75 copay after deductible 30% after deductible Outpatient Rehabilitation Therapy (20 combined visits per plan/calendar year for physical, occupational and speech therapy; In-Network and Out-of-Network combined) Chiropractic Services (20 visits per plan/calendar year; In-Network and Out-of-Network combined) Durable Medical Equipment ** ($1,000 Plan/Calendar Year Maximum; In-Network and Out-of-Network combined) PRESCRIPTION DRUGS MANDATORY GENERIC Retail (30 day supply) Mail Order (31-90 day supply) Aetna Specialty CareRx SM $25 copay after deductible 30% after deductible $25 copay after deductible 30% after deductible $25 copay after deductible 30% after deductible $25 copay after deductible 30% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible After Integrated Medical/ Pharmacy Deductible is met, $10/$25/$40 After Integrated Medical/ Pharmacy Deductible is met, $20/$50/$80 After Integrated Medical/ Pharmacy Deductible is met, 20% Not Covered Not Covered Not Covered After Integrated Medical/ Pharmacy Deductible is met, $10/$25/$40 After Integrated Medical/ Pharmacy Deductible is met, $20/$50/$80 After Integrated Medical/ Pharmacy Deductible is met, 20% Not Covered Not Covered Not Covered For footnotes, see page 17. 8

11 A E T N A O P E N AC C E S S Q P O S H S A C O M PAT I B L E P L A N O P T I O N S * PLAN OPTIONS OA QPOS D-10/10 HSA Compatible OA QPOS F-10/10 HSA Compatible MEMBER BENEFITS In-Network Out-of-Network In-Network Out-of-Network M E D I C A L Plan Coinsurance 0% after deductible 30% after deductible 0% after deductible 30% after deductible Plan Year Deductible o $3,500 Single $7,000 Family $5,500 Single $11,000 Family $4,500 Single $9,000 Family $6,000 Single $12,000 Family Plan Year Out-of-Pocket Maximum o $5,000 Single $10,000 Family $9,500 Single $19,000 Family $5,950 Single $11,900 Family $10,500 Single $21,000 Family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Primary Physician Office Visit $10 copay after deductible 30% after deductible $10 copay after deductible 30% after deductible Specialist Office Visit $25 copay after deductible 30% after deductible $25 copay after deductible 30% after deductible Wellness On Us SM Well-Child Exams, Immunizations, Routine GYN Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply) $0 copay; deductible waived 30% after deductible $0 copay; deductible waived 30% after deductible Adult Physicals (Age and frequency schedules apply) $0 copay; deductible waived Not Covered $0 copay; deductible waived Not Covered Aetna Vision SM Discount Program Included Not Covered Included Not Covered Outpatient Services Lab 0% after deductible 30% after deductible 0% after deductible 30% after deductible X-Ray $25 copay after deductible 30% after deductible $25 copay after deductible 30% after deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Inpatient Hospital Outpatient Surgery Outpatient Hospital Department Freestanding Surgical Facility Emergency Room (Copay waived if admitted) $75 copay per test after deductible up to a combined maximum of $375 per calendar year $250 copay per day up to a maximum of $1,000 per admission after deductible $250 copay after deductible $125 copay after deductible $150 copay after deductible 30% after deductible $75 copay per test after deductible up to a combined maximum of $375 per calendar year 30% after deductible $250 copay per day up to a maximum of $1,000 per admission after deductible 30% after deductible $250 copay after deductible 30% after deductible $125 copay after deductible Paid as In-Network $150 copay after deductible 30% after deductible 30% after deductible 30% after deductible 30% after deductible Paid as In-Network Urgent Care $75 copay after deductible 30% after deductible $75 copay after deductible 30% after deductible Outpatient Rehabilitation Therapy (20 combined visits per plan year for physical, occupational and speech therapy; In-Network and Out-of-Network combined) Chiropractic Services (20 visits per plan year; In-Network and Out-of-Network combined) Durable Medical Equipment ** ($1,000 PlanYear Maximum; In-Network and Out-of-Network combined) PRESCRIPTION DRUGS MANDATORY GENERIC Retail (30 day supply) Mail Order (31-90 day supply) Aetna Specialty CareRx SM $25 copay after deductible 30% after deductible $25 copay after deductible 30% after deductible $25 copay after deductible 30% after deductible $25 copay after deductible 30% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible After Integrated Medical/ Pharmacy Deductible is met, $10/$25/$40 After Integrated Medical/ Pharmacy Deductible is met, $20/$50/$80 After Integrated Medical/ Pharmacy Deductible is met, 20% Not Covered Not Covered Not Covered After Integrated Medical/ Pharmacy Deductible is met, $10/$25/$40 After Integrated Medical/ Pharmacy Deductible is met, $20/$50/$80 After Integrated Medical/ Pharmacy Deductible is met, 20% Not Covered Not Covered Not Covered For footnotes, see page 17. 9

12 C o n n e c t i c u t p l a n G U I D E A E T N A O P E N AC C E S S Q P O S P L A N O P T I O N S * PLAN OPTIONS OA QPOS 6-10/10 OA QPOS 7-10/10 MEMBER BENEFITS In-Network Out-of-Network In-Network Out-of-Network Plan Coinsurance N/A 30% after deductible N/A 30% after deductible Calendar Year Deductible *** $2,000 Individual $4,000 Family $3,000 Individual $6,000 Family $3,000 Individual $4,000 Individual $6,000 Family $8,000 Family Calendar Year Out-of-Pocket Maximum *** N/A $5,000 Individual $10,000 Family N/A $5,000 Individual $10,000 Family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Primary Care Physician Office Visit $25 copay 30% after deductible $30 copay 30% after deductible Specialist Office Visit $35 copay 30% after deductible $40 copay 30% after deductible Wellness On Us SM Well-Child Exams, Immunizations, Routine GYN Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply) Adult Physicals (Age and frequency schedules apply) $0 copay 30% after deductible $0 copay 30% after deductible $0 copay Not Covered $0 copay Not Covered Aetna Vision SM Discount Program Included Not Covered Included Not Covered Outpatient Services Lab $0 copay 30% after deductible $0 copay 30% after deductible X-ray $35 copay 30% after deductible $40 copay 30% after deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) $75 copay per test up to a combined maximum of $375 per calendar year 30% after deductible $75 copay per test up to a combined maximum of $375 per calendar year 30% after deductible Inpatient Hospital 0% after deductible 30% after deductible 0% after deductible 30% after deductible Outpatient Surgery Outpatient Hospital Department 0% after deductible 30% after deductible 0% after deductible 30% after deductible Freestanding Surgical Facility 0% after deductible 30% after deductible 0% after deductible 30% after deductible Emergency Room (Copay waived if admitted) $150 copay Paid as In-Network $150 copay Paid as In-Network Urgent Care $75 copay 30% after deductible $75 copay 30% after deductible Outpatient Rehabilitation Therapy (20 combined visits per calendar year for physical, occupational and speech therapy; In and Out-of-Network combined) Chiropractic Services (20 visits per calendar year; In and Out-of-Network combined) Durable Medical Equipment ** ($1,000 Calendar Year Maximum; In and Out-of-Network combined) PRESCRIPTION DRUGS MANDATORY GENERIC Retail (30 day supply) Mail Order (31-90 day supply) $35 copay 30% after deductible $40 copay 30% after deductible $35 copay 30% after deductible $40 copay 30% after deductible 50% 50% after deductible 50% 50% after deductible $10/$25/$40 Not Covered $10/$25/$40 Not Covered $20/$50/$80 Not Covered $20/$50/$80 Not Covered Aetna Specialty CareRx SM 20% Not Covered 20% Not Covered For footnotes, see page

13 M E D I C A L A E T N A O P E N AC C E S S Q P O S P L A N O P T I O N S * PLAN OPTIONS OA QPOS 8-10/10 OA QPOS 10-10/10 MEMBER BENEFITS In-Network Out-of-Network In-Network Out-of-Network Plan Coinsurance N/A 30% after deductible N/A 30% after deductible Calendar Year Deductible *** $5,000 Individual $10,000 Family $6,000 Individual $12,000 Family $4,000 Individual $5,000 Individual $8,000 Family $10,000 Family Calendar Year Out-of-Pocket Maximum *** N/A $5,000 Individual $10,000 Family N/A $5,000 Individual $10,000 Family Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Primary Care Physician Office Visit $30 copay 30% after deductible $30 copay 30% after deductible Specialist Office Visit $45 copay 30% after deductible $45 copay 30% after deductible Wellness On Us SM Well-Child Exams, Immunizations, Routine GYN Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply) Adult Physicals (Age and frequency schedules apply) $0 copay 30% after deductible $0 copay 30% after deductible $0 copay Not Covered $0 copay Not Covered Aetna Vision SM Discount Program Included Not Covered Included Not Covered Outpatient Services Lab $0 copay 30% after deductible $0 copay 30% after deductible X-ray $45 copay 30% after deductible $45 copay 30% after deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) $75 copay per test up to a combined maximum of $375 per calendar year 30% after deductible $75 copay per test up to a combined maximum of $375 per calendar year 30% after deductible Inpatient Hospital 0% after deductible 30% after deductible 0% after deductible 30% after deductible Outpatient Surgery Outpatient Hospital Department 0% after deductible 30% after deductible 0% after deductible 30% after deductible Freestanding Surgical Facility 0% after deductible 30% after deductible 0% after deductible 30% after deductible Emergency Room (Copay waived if admitted) $150 copay Paid as In-Network $150 copay Paid as In-Network Urgent Care $75 copay 30% after deductible $75 copay 30% after deductible Outpatient Rehabilitation Therapy (20 combined visits per calendar year for physical, occupational and speech therapy; In and Out-of-Network combined) Chiropractic Services (20 visits per calendar year; In and Out-of-Network combined) Durable Medical Equipment ** ($1,000 Calendar Year Maximum; In and Out-of-Network combined) PRESCRIPTION DRUGS MANDATORY GENERIC Retail (30 day supply) Mail Order (31-90 day supply) $45 copay 30% after deductible $45 copay 30% after deductible $45 copay 30% after deductible $45 copay 30% after deductible 50% 50% after deductible 50% 50% after deductible $10/$30/50% up to a maximum of $125 per script $20/$60/50% up to a maximum of $250 per script Not Covered $10/$25/$40 Not Covered Not Covered $20/$50/$80 Not Covered Aetna Specialty CareRx SM 50% Not Covered 20% Not Covered For footnotes, see page

14 C o n n e c t i c u t p l a n G U I D E A E T N A O P E N AC C E S S Q P O S P L A N O P T I O N S * PLAN OPTIONS OA QPOS 12-10/10 MEMBER BENEFITS In-Network Out-of-Network Plan Coinsurance N/A 30% after deductible Calendar Year Deductible *** $3,500 Individual $7,000 Family $5,000 Individual $10,000 Family Calendar Year Out-of-Pocket Maximum *** N/A $5,000 Individual $10,000 Family Lifetime Maximum Benefit Unlimited Unlimited Primary Care Physician Office Visit $25 copay after deductible 30% after deductible Specialist Office Visit $40 copay after deductible 30% after deductible Wellness On Us SM Well-Child Exams, Immunizations, Routine GYN Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply) $0 copay; deductible waived 30% after deductible Adult Physicals (Age and frequency schedules apply) $0 copay; deductible waived Not Covered Aetna Vision SM Discount Program Included Not Covered Outpatient Services Lab $0 copay after deductible 30% after deductible X-ray $40 copay after deductible 30% after deductible Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Inpatient Hospital Outpatient Surgery Outpatient Hospital Department Freestanding Surgical Facility Emergency Room (Copay waived if admitted) $75 copay per test after deductible up to a combined maximum of $375 per calendar year $500 copay per admission after deductible $250 copay after deductible $125 copay after deductible $150 copay after deductible 30% after deductible 30% after deductible 30% after deductible 30% after deductible Paid as In-Network Urgent Care $75 copay after deductible 30% after deductible Outpatient Rehabilitation Therapy (20 combined visits per calendar year for physical, occupational and speech therapy; In and Out-of-Network combined) Chiropractic Services (20 visits per calendar year; In and Out-of-Network combined) Durable Medical Equipment ** ($1,000 Calendar Year Maximum; In and Out-of-Network combined) PRESCRIPTION DRUGS MANDATORY GENERIC Retail (30 day supply) Mail Order (31-90 day supply) $40 copay after deductible 30% after deductible $40 copay after deductible 30% after deductible 50% after deductible 50% after deductible $10/$30/50% up to a maximum of $125 per script $20/$60/50% up to a maximum of $250 per script Not Covered Not Covered Aetna Specialty CareRx SM 50% Not Covered For footnotes, see page

15 A E T N A O P E N AC C E S S M A N AG E D C H O I C E H S A C O M PAT I B L E P L A N O P T I O N * PLAN OPTIONS OA MC B-10/10 HSA Compatible MEMBER BENEFITS Network Out-of-Network Plan Coinsurance 20% after deductible 40% after deductible Plan Year Deductible o $3,000 Single $6,000 Family $4,000 Single $8,000 Family M E D I C A L Plan Year Maximum Out-of-Pocket Limit o $5,000 Single $10,000 Family $5,000 Single $10,000 Family Lifetime Maximum Benefit Unlimited Unlimited Primary Physician Office Visit 20% after deductible 40% after deductible Specialist Office Visit 20% after deductible 40% after deductible Wellness On Us SM Well-Child Exams, Immunizations, Adult Physicals, Routine GYN Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply) $0 copay; deductible waived 40% after deductible Aetna Vision SM Discount Program Included Not Covered Outpatient Services (Lab & X-Ray) Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) 20% after deductible 40% after deductible 20% after deductible 40% after deductible Inpatient Hospital 20% after deductible 40% after deductible Outpatient Surgery (Outpatient Hospital Department and Freestanding Surgical Facility) 20% after deductible 40% after deductible Emergency Room 20% after deductible Paid as Network Urgent Care 20% after deductible 40% after deductible Outpatient Rehabilitation Therapy (20 combined visits per plan year for physical, occupational and speech therapy; Network and Out-of-Network combined) Chiropractic Services (20 visits per plan year; Network and Out-of-Network combined) Durable Medical Equipment ** ($1,000 Plan Year Maximum; Network and Out-of-Network combined) 20% after deductible 40% after deductible 20% after deductible 40% after deductible 50% after deductible 50% after deductible PRESCRIPTION DRUGS MANDATORY GENERIC Retail (30 day supply) Mail Order (31-90 day supply) Aetna Specialty CareRx SM After Integrated Medical/ Pharmacy Deductible is met, $10/$25/$40 After Integrated Medical/ Pharmacy Deductible is met, $20/$50/$80 After Integrated Medical/ Pharmacy Deductible is met, 20% After Integrated Medical/ Pharmacy Deductible is met, $10/$25/$40 plus 20% Not Covered After Integrated Medical/ Pharmacy Deductible is met, 20% For footnotes, see page

16 C o n n e c t i c u t p l a n G U I D E A E T N A O P E N AC C E S S M A N AG E D C H O I C E P L A N O P T I O N * PLAN OPTIONS OA MC 2-10/10 MEMBER BENEFITS Network Out-of-Network Plan Coinsurance 10% after deductible 30% after deductible Calendar Year Deductible # $2,000 Individual $4,000 Family $4,000 Individual $8,000 Family Calendar Year Maximum Out-of-Pocket Limit # $2,000 Individual $4,000 Family $5,000 Individual $10,000 Family Lifetime Maximum Benefit Unlimited Unlimited Primary Care Physician Office Visit Specialist Office Visit Wellness On Us SM Well-Child Exams, Immunizations, Adult Physicals, Routine GYN Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply) $25 copay; deductible waived $35 copay; deductible waived $0 copay; deductible waived 30% after deductible 30% after deductible 30% after deductible Aetna Vision SM Discount Program Included Not Covered Outpatient Services (Lab & X-Ray) Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) 10% after deductible 30% after deductible 10% after deductible 30% after deductible Inpatient Hospital 10% after deductible 30% after deductible Outpatient Surgery (Outpatient Hospital Department and Freestanding Surgical Facility) 10% after deductible 30% after deductible Emergency Room (Copay waived if admitted) Urgent Care Outpatient Rehabilitation Therapy (20 combined visits per calendar year for physical, occupational and speech therapy; In and Out-of-Network combined) Chiropractic Services (20 visits per calendar year; In and Out-of-Network combined) Durable Medical Equipment ** ($1,000 Calendar Year Maximum; In and Out-of-Network combined) PRESCRIPTION DRUGS MANDATORY GENERIC Retail (30 day supply) Mail Order (31-90 day supply) $150 copay; deductible waived $75 copay; deductible waived Paid as Network 30% after deductible 10% after deductible 30% after deductible $35 copay; deductible waived 30% after deductible 50% after deductible 50% after deductible $10/$25/$40 $10/$25/$40 plus 20% $20/$50/$80 Not Covered Aetna Specialty CareRx SM 20% 20% For footnotes, see page

17 A E T N A T R A D I T I O N A L C H O I C E H S A C O M PAT I B L E P L A N O P T I O N * PLAN OPTIONS MEMBER BENEFITS Plan Coinsurance Calendar Year Deductible TC 1-10/10 HSA Compatible 20% after deductible $3,000 Individual $6,000 Family M E D I C A L Calendar Year Maximum Out-of-Pocket Limit Lifetime Maximum Benefit Primary Care Physician Office Visit Specialist Office Visit $2,950 Individual $5,900 Family Unlimited 20% after deductible 20% after deductible Wellness On Us SM Well-Child Exams, Immunizations, Adult Physicals, Routine GYN Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply) Aetna Vision SM Discount Program Outpatient Services (Lab & X-Ray) Outpatient Complex Imaging (MRA/MRS, MRI, PET and CAT Scans) Inpatient Hospital Outpatient Surgery (Outpatient Hospital Department and Freestanding Surgical Facility) Emergency Room Urgent Care Outpatient Rehabilitation Therapy (20 combined visits per calendar year for physical, occupational and speech therapy; In and Out-of-Network combined) Chiropractic Services (20 visits per calendar year; In and Out-of-Network combined) Durable Medical Equipment ** ($1,000 Calendar Year Maximum; In and Out-of-Network combined) PRESCRIPTION DRUGS MANDATORY GENERIC Retail (30 day supply) Mail Order (31-90 day supply) Aetna Specialty CareRx SM $0 copay; deductible waived Included 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 50% after deductible After Integrated Medical/ Pharmacy Deductible is met, $10/$25/$40 After Integrated Medical/ Pharmacy Deductible is met, $20/$50/$80 After Integrated Medical/ Pharmacy Deductible is met, 20% For footnotes, see page

18 C o n n e c t i c u t p l a n G U I D E 16

19 M E D I C A L FoOtnotes The federal health care reform legislation known as the Patient Protection and Affordable Care Act was signed into law on March 23, A number of new reforms are effective September 23, 2010, including coverage for dependents up to age 26, elimination of lifetime benefit dollar maximums, restriction of annual dollar maximums on essential health benefits, removal of cost sharing for preventive services and elimination of pre-existing condition exclusions for dependent children under 19 years of age. Your Aetna Avenue benefit program does comply with the new reform legislation. * This is a partial description of plans and benefits available; for more information, refer to Aetna s Producer World website at for specific plan design benefit descriptions or please contact your licensed agent or Aetna Sales Representative. ** Certain covered DME benefits may not be subject to the DME maximum benefit listed, but may be subject to a separate maximum benefit. *** All covered expenses accumulate separately toward the In-Network and Out-of-Network Deductible and Out-of-Pocket Maximum; only those out-of-pocket expenses resulting from the application of coinsurance percentage may be used to satisfy the Out-of-Pocket Maximum; and certain services may not apply toward the Deductible or Out-of-Pocket Maximum. Once the Family Deductible/Out-of-Pocket Maximum is met, all family members will be considered as having met their Deductible/Out-of-Pocket Maximum for the remainder of the calendar year. No one family member may contribute more than the Individual Deductible/Out-of-Pocket Maximum amount to the Family Deductible/Out-of- Pocket Maximum. # All covered expenses accumulate separately toward the Network and Out-of-Network Deductible and Maximum Out-of-Pocket Limit; only those out-of-pocket expenses resulting from the application of coinsurance percentage may be used to satisfy the Maximum Out-of-Pocket Limit; and certain services may not apply toward the Deductible or Maximum Out-of-Pocket Limit. Once the Family Deductible/Maximum Out-of-Pocket Limit is met, all family members will be considered as having met their Deductible/ Maximum Out-of-Pocket Limit for the remainder of the calendar year. No one family member may contribute more than the Individual Deductible/Maximum Out-of-Pocket Limit amount to the Family Deductible/Maximum Out-of-Pocket Limit. TC 1-10/10 HSA Compatible plan is administered on a calendar year basis. All covered expenses, including prescription drugs, accumulate toward the Deductible and Maximum Out-of-Pocket Limit; only those out-of-pocket expenses resulting from the application of coinsurance percentage and copays, including prescription drug copays, may be used to satisfy the Maximum Out-of-Pocket Limit. The Individual Deductible/Maximum Out-of-Pocket Limit can only be met when a member is enrolled for self-only coverage with no dependent coverage. The Family Deductible/Maximum Out-of-Pocket Limit can be met by a combination of family members or by any single individual within the family. Once the Family Deductible/Maximum Out-of-Pocket Limit is met, all family members will be considered as having met their Deductible/Maximum Out-of-Pocket Limit for the remainder of the calendar year. o OA QPOS Ac-10/10 HSA Compatible plan is administered on a calendar year basis. OA QPOS Ap-10/10, OA QPOS D-10/10 & OA QPOS F-10/10 HSA Compatible plans are administered on a plan year basis. All covered expenses, including prescription drugs, accumulate separately toward the In-Network and Out-of-Network Deductible and Outof-Pocket Maximum; only those out-of-pocket expenses resulting from the application of deductible, coinsurance percentage and copays, including prescription drug copays, may be used to satisfy the Out-of-Pocket Maximum. The Individual Deductible/Out-of-Pocket Maximum can only be met when a member is enrolled for self-only coverage with no dependent coverage. The Family Deductible/Out-of-Pocket Maximum can be met by a combination of family members or by any single individual within the family. Once the Family Deductible/Out-of-Pocket Maximum is met, all family members will be considered as having met their Deductible/Out-of-Pocket Maximum for the remainder of the plan/calendar year. o OA MC B-10/10 HSA Compatible plan is administered on a plan year basis. All covered expenses, including prescription drugs, accumulate separately toward the Network and Out-of-Network Deductible and Maximum Out-of-Pocket Limit; only those out-of-pocket expenses resulting from the application of coinsurance percentage and copays, including prescription drug copays, may be used to satisfy the Maximum Out-of-Pocket Limit. The Individual Deductible/Maximum Out-of-Pocket Limit can only be met when a member is enrolled for self-only coverage with no dependent coverage. The Family Deductible/Maximum Out-of-Pocket Limit can be met by a combination of family members or by any single individual within the family. Once the Family Deductible/Maximum Out-of-Pocket Limit is met, all family members will be considered as having met their Deductible/Maximum Out-of-Pocket Limit for the remainder of the plan year. Based upon Treasury guidance available as of the print date. See page 6 for Aetna HealthFund HSA information. In-Network deductible only applies to inpatient hospital admissions and outpatient surgery. Pharmacy plans include Prior Authorization and Step-Therapy. 90-Day Transition of Coverage (TOC) for Prior Authorization and Step-Therapy included on pharmacy plans. Transition of Coverage for Prior Authorization and Step-Therapy helps members of new groups to transition to Aetna by providing a 90-calendar-day opportunity, beginning on the group s initial effective date, during which time Prior Authorization and Step-Therapy requirements will not apply to certain drugs. Once the 90 calendar days has expired, Prior Authorization and Step-Therapy edits will apply to all drugs requiring Prior Authorization and Step-Therapy as listed in the formulary guide. Members, who have claims paid for a drug requiring Prior Authorization and Step-Therapy during the Transition of Coverage period, may continue to receive this drug after the 90 calendar days and will not be required to obtain a Prior Authorization or approval for a medical exception for this drug. NOTE: Step-Therapy and TOC for Step-Therapy are not included on HSA compatible plans. Groups of one will be offered the following CT State Mandated Plans pursuant to CT state law: CSEHRP HMO or CSEHRP TC. For plan design benefit descriptions for these plans, please refer to Aetna s Producer World website at or please contact your licensed agent or Aetna Sales Representative. Some benefits are subject to limitations or visit maximums. Members or Providers may be required to pre-certify or obtain prior approval for certain services. The dollar amount and percentage copayments indicate what the member is required to pay. You may choose providers in our network (physicians and facilities) or may visit an out-of-network provider. Typically, you will pay substantially more money out of your own pocket if you choose to use an out-of-network doctor. The out-of-network provider will be paid based on Aetna s recognized charge. This is not the same as the billed charge from the doctor. Aetna pays a percentage of the recognized charge, as defined in Your plan. The recognized charge for out-of-network hospitals, doctors and other out-of-network health care providers is a percentage (100 percent or above) of the rate that Medicare pays them. You may have to pay the difference between the out-of-network provider s billed charge and Aetna s recognized charge, plus any coinsurance and deductibles due under the plan. Note that any amount the doctor or hospital bills you above Aetna s recognized charge does not count toward your deductible or out-of-pocket maximums. This benefit applies when you choose to get care out of network. When you have no choice in the doctors you see (for example, an emergency room visit after a car accident), your deductible and coinsurance for the in-network level of benefits will be applied, and you should contact Aetna if your doctor asks you to pay more. Generally, you are not responsible for any outstanding balance billed by your doctors in an emergency situation. Note: For a summary list of Limitations and Exclusions, refer to pages

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

21 D E N TA L Preferred Provider Organization (PPO) plan Members can choose a dentist who participates in the network or choose a licensed dentist who does not. Participating dentists have agreed to offer our members services at a negotiated rate and will not balance-bill members.* PPO Max plan While the PPO Max dental insurance plan uses the PPO network, when members use out-of-network dentists the service will be covered based on the PPO fee schedule, rather than the usual and customary charge. The member will share in more of the costs and may be balance-billed. This plan offers members a quality dental insurance plan with a significantly lower premium that encourages in-network usage. Freedom-of-Choice plan design option Get maximum flexibility with our two-in-one dental plan design. The Freedom-of-Choice plan design option provides the administrative ease of one plan, yet members get to choose between the DMO and PPO plans on a monthly basis. One blended rate is paid. Members may switch between the plans on a monthly basis by calling Member Services. Plan changes must be made by the 15th of the month to be effective the following month. Dual Option** plan In the Dual Option plan design, the DMO must be packaged with any one of the PPO plans. Employees may choose between the DMO and PPO offerings at annual enrollment. Voluntary Dental option The Voluntary Dental option provides a solution to meet the individual needs of members in the face of rising health care costs. Administration is easy, and members benefit from low group rates and the convenience of payroll deductions. Employers choose how the plan is funded. It can be entirely member-paid or employers can contribute up to 50 percent. Aetna Dental Preventive Care SM plan The Preventive Care plan is a lower cost dental plan that covers preventive and diagnostic procedures. Members pay nothing for these services and may get a discount on the network dentist s charges for non-covered services when visiting an Aetna PPO dentist. This includes orthodontic work for adults and teeth whitening.* *Discounts for non-covered services may not be available. Discounts are not insurance. **Dual Option does not apply to Preventive or Voluntary Dental plans. 19

22 C o n n e c t i c u t p l a n G U I D E S m a l l G r o u p D e n ta l P l a n s Available With an Aetna Medical Plan to Groups with 2-50 Eligible Employees Available Without Medical Plan to Groups with 3-50 Eligible Employees Option 1 Preventive Care Preventive Care/ PPO Max 100/0/0 Option 2 Freedom-of-Choice Monthly selection between DMO and PPO DMO Plan Copay Plan 64 PPO Max Plan 100/80/50 Option 3 PPO Max PPO Max Plan 100/80/50 Office Visit Copay N/A $5 N/A N/A Annual Deductible per Member None None $50; 3X Family Maximum $50; 3X Family Maximum (does not apply to Diagnostic & Preventive Services) Annual Maximum Benefit Unlimited None $1,000 $1,500 Diagnostic Services Oral Exams Periodic oral exam 100% No Charge 100% 100% Comprehensive oral exam 100% No Charge 100% 100% Problem-focused oral exam 100% No Charge 100% 100% X-rays Bitewing single film 100% No Charge 100% 100% Complete series 100% No Charge 100% 100% Preventive Services Adult Cleaning 100% No Charge 100% 100% Child Cleaning 100% No Charge 100% 100% Sealants per tooth 100% No Charge 100% 100% Fluoride application with cleaning 100% No Charge 100% 100% Space maintainers 100% $75 100% 100% Basic Services Amalgam filling 2 surfaces Not covered $12 80% 80% Resin filling 2 surfaces, anterior Not covered $21 80% 80% Oral Surgery Extraction exposed root or erupted tooth Not covered $11 80% 80% Extraction of impacted tooth soft tissue Not covered $46 80% 80% *Major Services Complete upper denture Not covered $275 50% 50% Partial upper denture (resin base) Not covered $275 50% 50% Crown Porcelain with noble metal** Not covered $255 50% 50% Pontic Porcelain with noble metal** Not covered $255 50% 50% Inlay Metallic (3 or more surfaces) Not covered $195 50% 50% Oral Surgery Removal of impacted tooth partially bony Not covered $58 50% 50% Endodontic Services Bicuspid root canal therapy Not covered $109 50% 50% Molar root canal therapy Not covered $280 50% 50% Periodontic Services Scaling & root planing per quadrant Not covered $51 50% 50% Osseous surgery per quadrant Not covered $300 50% 50% *Orthodontic Services Not covered $2,300 copay Not covered Not covered Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply Does not apply * Coverage Waiting Period: Must be an enrolled member of the plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Does not apply to the DMO in Plan Options 2 & 4 and the PPO in Plan Option 1. ** There will be an additional patient charge for the actual cost for gold/high noble metal for these procedures in DMO Option 2. Access to negotiated discounts: On the PPO plans in Plan Options 1-7, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the DMO in Plan Options 2 & 4. All Endodontic, Periodontic and oral surgical services are covered as Basic services on PPO Plan Option 7. Plan Options 1, 2 & 3; PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. Fixed dollar amounts on the DMO in DMO Options 2 and 4 are the member s responsibility. Out-of-Network plan payments are limited by geographic area on Plan Options 4, 5, and 6 to the prevailing fees at the 80th percentile and the 90th percentile on Plan Option 7. Orthodontic coverage is available only to groups with 10 or more eligibles and for dependent children only. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page

23 S m a l l G r o u p D e n ta l P l a n s D E N TA L Available With an Aetna Medical Plan to Groups with 2-50 Eligible Employees Available Without Medical Plan to Groups with 3-50 Eligible Employees Option 4 Freedom-of-Choice Monthly selection between the DMO and PPO DMO Plan 100/100/60 PPO Plan 100/80/50 Preferred Plan 100/80/50 Option 5 Active PPO Plan Non-Preferred Plan 80/60/50 Office Visit Copay $5 N/A N/A N/A Annual Deductible per Member None $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum (does not apply to Diagnostic & Preventive Services) Annual Maximum Benefit None $1,000 $1,500 $1,000 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% 80% Comprehensive oral exam 100% 100% 100% 80% Problem-focused oral exam 100% 100% 100% 80% X-rays Bitewing single film 100% 100% 100% 80% Complete series 100% 100% 100% 80% Preventive Services Adult Cleaning 100% 100% 100% 80% Child Cleaning 100% 100% 100% 80% Sealants per tooth 100% 100% 100% 80% Fluoride application with cleaning 100% 100% 100% 80% Space maintainers 100% 100% 100% 80% Basic Services Amalgam filling 2 surfaces 100% 80% 80% 60% Resin filling 2 surfaces, anterior 100% 80% 80% 60% Oral Surgery Extraction exposed root or erupted tooth 100% 80% 80% 60% Extraction of impacted tooth soft tissue 100% 80% 80% 60% *Major Services Complete upper denture 60% 50% 50% 50% Partial upper denture (resin base) 60% 50% 50% 50% Crown Porcelain with noble metal** 60% 50% 50% 50% Pontic Porcelain with noble metal** 60% 50% 50% 50% Inlay Metallic (3 or more surfaces) 60% 50% 50% 50% Oral Surgery Removal of impacted tooth partially bony 60% 50% 50% 50% Endodontic Services Bicuspid root canal therapy 100% 50% 50% 50% Molar root canal therapy 60% 50% 50% 50% Periodontic Services Scaling & root planing per quadrant 100% 50% 50% 50% Osseous surgery per quadrant 60% 50% 50% 50% *Orthodontic Services $2,300 copay Not covered 50% 50% Orthodontic Lifetime Maximum Does not apply Does not apply $1,000 $1,000 * Coverage Waiting Period: Must be an enrolled member of the plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Does not apply to the DMO in Plan Options 2 & 4 and the PPO in Plan Option 1. ** There will be an additional patient charge for the actual cost for gold/high noble metal for these procedures in DMO Option 2. Access to negotiated discounts: On the PPO plans in Plan Options 1-7, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the DMO in Plan Options 2 & 4. All Endodontic, Periodontic and oral surgical services are covered as Basic services on PPO Plan Option 7. Plan Options 1, 2 & 3; PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. Fixed dollar amounts on the DMO in DMO Options 2 and 4 are the member s responsibility. Out-of-Network plan payments are limited by geographic area on Plan Options 4, 5, and 6 to the prevailing fees at the 80th percentile and the 90th percentile on Plan Option 7. Orthodontic coverage is available only to groups with 10 or more eligibles and for dependent children only. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page

24 C o n n e c t i c u t p l a n G U I D E S m a l l G r o u p D e n ta l P l a n s Available With an Aetna Medical Plan to Groups with 2-50 Eligible Employees Available Without Medical Plan to Groups with 3-50 Eligible Employees Option 6 PPO 1500 PPO Plan 100/80/50 Office Visit Copay N/A N/A Annual Deductible per Member (does not apply to Diagnostic & Preventive Services) Option 7 PPO PPO Plan 100/80/50 $50; 3X Family Maximum $50; 3X Family Maximum Annual Maximum Benefit $1,500 $2,000 Diagnostic Services Oral Exams Periodic oral exam 100% 100% Comprehensive oral exam 100% 100% Problem-focused oral exam 100% 100% X-rays Bitewing single film 100% 100% Complete series 100% 100% Preventive Services Adult Cleaning 100% 100% Child Cleaning 100% 100% Sealants per tooth 100% 100% Fluoride application with cleaning 100% 100% Space maintainers 100% 100% Basic Services Amalgam filling 2 surfaces 80% 80% Resin filling 2 surfaces, anterior 80% 80% Oral Surgery Extraction exposed root or erupted tooth 80% 80% Extraction of impacted tooth soft tissue 80% 80% *Major Services Complete upper denture 50% 50% Partial upper denture (resin base) 50% 50% Crown Porcelain with noble metal** 50% 50% Pontic Porcelain with noble metal** 50% 50% Inlay Metallic (3 or more surfaces) 50% 50% Oral Surgery Removal of impacted tooth partially bony 50% 80% Endodontic Services Bicuspid root canal therapy 50% 80% Molar root canal therapy 50% 80% Periodontic Services Scaling & root planing per quadrant 50% 80% Osseous surgery per quadrant 50% 80% *Orthodontic Services 50% 50% Orthodontic Lifetime Maximum $1,000 $1,000 * Coverage Waiting Period: Must be an enrolled member of the plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Does not apply to the DMO in Plan Options 2 & 4 and the PPO in Plan Option 1. ** There will be an additional patient charge for the actual cost for gold/high noble metal for these procedures in DMO Option 2. Access to negotiated discounts: On the PPO plans in Plan Options 1-7, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the DMO in Plan Options 2 & 4. All Endodontic, Periodontic and oral surgical services are covered as Basic services on PPO Plan Option 7. Plan Options 1, 2 & 3; PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. Fixed dollar amounts on the DMO in DMO Options 2 and 4 are the member s responsibility. Out-of-Network plan payments are limited by geographic area on Plan Options 4, 5, and 6 to the prevailing fees at the 80th percentile and the 90th percentile on Plan Option 7. Orthodontic coverage is available only to groups with 10 or more eligibles and for dependent children only. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page

25 V o l u n ta r y S m a l l G r o u p D e n ta l P l a n s D E N TA L Available With an Aetna Medical Plan to Groups with 3-50 Eligible Employees Available Without Medical Plan to Groups with 3-50 Eligible Employees Voluntary Opt 1 PPO Max PPO Max Plan 100/80/50 Voluntary Opt 2 Freedom-of-Choice Monthly selection between the DMO and PPO DMO Plan 100/100/60 Office Visit Copay N/A $10 N/A Annual Deductible per Member (does not apply to Diagnostic & Preventive Services) PPO Plan 100/80/50 $75; 3X Family Maximum None $75; 3X Family Maximum Annual Maximum Benefit $1,500 None $1,000 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% Comprehensive oral exam 100% 100% 100% Problem-focused oral exam 100% 100% 100% X-rays Bitewing single film 100% 100% 100% Complete series 100% 100% 100% Preventive Services Adult Cleaning 100% 100% 100% Child Cleaning 100% 100% 100% Sealants per tooth 100% 100% 100% Fluoride application with cleaning 100% 100% 100% Space maintainers 100% 100% 100% Basic Services Amalgam filling 2 surfaces 80% 100% 80% Resin filling 2 surfaces, anterior 80% 100% 80% Oral Surgery Extraction exposed root or erupted tooth 80% 100% 80% Extraction of impacted tooth soft tissue 80% 100% 80% *Major Services Complete upper denture 50% 60% 50% Partial upper denture (resin base) 50% 60% 50% Crown Porcelain with noble metal 50% 60% 50% Pontic Porcelain with noble metal 50% 60% 50% Inlay Metallic (3 or more surfaces) 50% 60% 50% Oral Surgery Removal of impacted tooth partially bony 50% 60% 50% Endodontic Services Bicuspid root canal therapy 50% 100% 50% Molar root canal therapy 50% 60% 50% Periodontic Services Scaling & root planing per quadrant 50% 100% 50% Osseous surgery per quadrant 50% 60% 50% *Orthodontic Services Not covered $2400 copay Not covered Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply * Coverage Waiting Period: Must be an enrolled member of the plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Does not apply to the DMO in Voluntary Plan Option 2 and the PPO in Plan Option 5. Access to negotiated discounts: On the PPO plans in Plan Options 1-3, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the DMO in Plan Option 2. All Endodontic, Periodontic and oral surgical services are covered as Basic services on PPO Plan Option 4. Fixed dollar amounts on the DMO in Voluntary Option 2 are the member s responsibility. Plan Options 1, 4 & 5: PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. Orthodontic coverage is available only to groups with 10 or more eligibles and for dependent children only. If there is a lapse in coverage, members may not re-enroll in the plan for a period of two years from the date of termination. If they are eligible for coverage at that time, they may re-enroll, subject to all provisions of the plan, including, but not limited to, the Coverage Waiting Period. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page

26 C o n n e c t i c u t p l a n G U I D E V o l u n ta r y S m a l l G r o u p D e n ta l P l a n s Available With an Aetna Medical Plan to Groups with 3-50 Eligible Employees Available Without Medical Plan to Groups with 3-50 Eligible Employees Preferred Plan 100/80/50 Voluntary Opt 3 Active PPO Plan Office Visit Copay N/A N/A Annual Deductible per Member (does not apply to Diagnostic & Preventive Services) Non-Preferred Plan 80/60/50 $75; 3X Family Maximum $75; 3X Family Maximum Annual Maximum Benefit $1,500 $1,000 Diagnostic Services Oral Exams Periodic oral exam 100% 80% Comprehensive oral exam 100% 80% Problem-focused oral exam 100% 80% X-rays Bitewing single film 100% 80% Complete series 100% 80% Preventive Services Adult Cleaning 100% 80% Child Cleaning 100% 80% Sealants per tooth 100% 80% Fluoride application with cleaning 100% 80% Space maintainers 100% 80% Basic Services Amalgam filling 2 surfaces 80% 60% Resin filling 2 surfaces, anterior 80% 60% Oral Surgery Extraction exposed root or erupted tooth 80% 60% Extraction of impacted tooth soft tissue 80% 60% *Major Services Complete upper denture 50% 50% Partial upper denture (resin base) 50% 50% Crown Porcelain with noble metal 50% 50% Pontic Porcelain with noble metal 50% 50% Inlay Metallic (3 or more surfaces) 50% 50% Oral Surgery Removal of impacted tooth partially bony 50% 50% Endodontic Services Bicuspid root canal therapy 50% 50% Molar root canal therapy 50% 50% Periodontic Services Scaling & root planing per quadrant 50% 50% Osseous surgery per quadrant 50% 50% *Orthodontic Services 50% 50% Orthodontic Lifetime Maximum $1,000 $1,000 * Coverage Waiting Period: Must be an enrolled member of the plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Does not apply to the DMO in Voluntary Plan Option 2 and the PPO in Plan Option 5. Access to negotiated discounts: On the PPO plans in Plan Options 1-3, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the DMO in Plan Option 2. All Endodontic, Periodontic and oral surgical services are covered as Basic services on PPO Plan Option 4. Fixed dollar amounts on the DMO in Voluntary Option 2 are the member s responsibility. Plan Options 1, 4 & 5: PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. Orthodontic coverage is available only to groups with 10 or more eligibles and for dependent children only. If there is a lapse in coverage, members may not re-enroll in the plan for a period of two years from the date of termination. If they are eligible for coverage at that time, they may re-enroll, subject to all provisions of the plan, including, but not limited to, the Coverage Waiting Period. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page

27 V o l u n ta r y S m a l l G r o u p D e n ta l P l a n s D E N TA L Available With an Aetna Medical Plan to Groups with 3-50 Eligible Employees Available Without Medical Plan to Groups with 3-50 Eligible Employees Voluntary Opt 4 PPO Max High PPO Max Plan 100/80/50 Office Visit Copay N/A N/A Annual Deductible per Member $75; 3X Family Maximum None (does not apply to Diagnostic & Preventive Services) Annual Maximum Benefit $2,000 Unlimited Diagnostic Services Oral Exams Periodic oral exam 100% 100% Comprehensive oral exam 100% 100% Problem-focused oral exam 100% 100% X-rays Bitewing single film 100% 100% Complete series 100% 100% Preventive Services Adult Cleaning 100% 100% Child Cleaning 100% 100% Sealants per tooth 100% 100% Fluoride application with cleaning 100% 100% Space maintainers 100% 100% Voluntary Opt 5 Preventive Care PPO Max PPO Max 100/0/0 Basic Services Amalgam filling 2 surfaces 80% Not covered Resin filling 2 surfaces, anterior 80% Not covered Oral Surgery Extraction exposed root or erupted tooth 80% Not covered Extraction of impacted tooth soft tissue 80% Not covered *Major Services Complete upper denture 50% Not covered Partial upper denture (resin base) 50% Not covered Crown Porcelain with noble metal 50% Not covered Pontic Porcelain with noble metal 50% Not covered Inlay Metallic (3 or more surfaces) 50% Not covered Oral Surgery Removal of impacted tooth partially bony 80% Not covered Endodontic Services Bicuspid root canal therapy 80% Not covered Molar root canal therapy 80% Not covered Periodontic Services Scaling & root planing per quadrant 80% Not covered Osseous surgery per quadrant 80% Not covered *Orthodontic Services 50% Not covered Orthodontic Lifetime Maximum $1,000 Does not apply * Coverage Waiting Period: Must be an enrolled member of the plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Does not apply to the DMO in Voluntary Plan Option 2 and the PPO in Plan Option 5. Access to negotiated discounts: On the PPO plans in Plan Options 1-3, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the DMO in Plan Option 2. All Endodontic, Periodontic and oral surgical services are covered as Basic services on PPO Plan Option 4. Fixed dollar amounts on the DMO in Voluntary Option 2 are the member s responsibility. Plan Options 1, 4 & 5: PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. Orthodontic coverage is available only to groups with 10 or more eligibles and for dependent children only. If there is a lapse in coverage, members may not re-enroll in the plan for a period of two years from the date of termination. If they are eligible for coverage at that time, they may re-enroll, subject to all provisions of the plan, including, but not limited to, the Coverage Waiting Period. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page

28 C o n n e c t i c u t p l a n G U I D E O u t- o f - S tat e P P O S m a l l G r o u p D e n ta l P l a n s Dental Plans PPO 1000 PPO 1500 PPO Max Plan 100/80/50 Office Visit Copay N/A N/A Annual Deductible per Member (does not apply to Diagnostic & Preventive Services) PPO Max Plan 100/80/50 $50; 3X Family Maximum $50; 3X Family Maximum Annual Maximum Benefit $1,000 $1,500 Diagnostic Services Oral Exams Periodic oral exam 100% 100% Comprehensive oral exam 100% 100% Problem-focused oral exam 100% 100% X-rays Bitewing single film 100% 100% Complete series 100% 100% Preventive Services Adult Cleaning 100% 100% Child Cleaning 100% 100% Sealants per tooth 100% 100% Fluoride application with cleaning 100% 100% Space maintainers 100% 100% Basic Services Amalgam filling 2 surfaces 80% 80% Resin filling 2 surfaces, anterior 80% 80% Oral Surgery Extraction exposed root or erupted tooth 80% 80% Extraction of impacted tooth soft tissue 80% 80% *Major Services Complete upper denture 50% 50% Partial upper denture (resin base) 50% 50% Crown Porcelain with noble metal 50% 50% Pontic Porcelain with noble metal 50% 50% Inlay Metallic (3 or more surfaces) 50% 50% Oral Surgery Removal of impacted tooth partially bony 50% 50% Endodontic Services Bicuspid root canal therapy 50% 50% Molar root canal therapy 50% 50% Periodontic Services Scaling & root planing per quadrant 50% 50% Osseous surgery per quadrant 50% 50% *Orthodontic Services 50% 50% Orthodontic Lifetime Maximum $1,000 $1,000 * Coverage Waiting Period: Must be an enrolled member of the plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Access to negotiated discounts: On all PPO Max Plans, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. Orthodontic coverage is available only to groups with 10 or more eligibles and for dependent children only. OOS Voluntary: If there is a lapse in coverage, members may not re-enroll in the plan for a period of two years from the date of termination. If they are eligible for coverage at that time, they may re-enroll, subject to all provisions of the plan, including, but not limited to, the Coverage Waiting Period. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page 46. For out-of-state employees in all states except: Arkansas, Alaska, Hawaii, Idaho, Maine, Massachusetts, Montana, North Carolina, North Dakota, New Hampshire, New Mexico, South Dakota, Vermont, Wyoming. 26

29 O u t- o f - S tat e P P O S m a l l G r o u p D e n ta l P l a n s D E N TA L Dental Plans PPO 2000 Voluntary PPO 1000 PPO Max Plan 100/80/50 Office Visit Copay N/A N/A Annual Deductible per Member (does not apply to Diagnostic & Preventive Services) PPO Max Plan 100/80/50 $50; 3X Family Maximum $75; 3X Family Maximum Annual Maximum Benefit $2,000 $1,000 Diagnostic Services Oral Exams Periodic oral exam 100% 100% Comprehensive oral exam 100% 100% Problem-focused oral exam 100% 100% X-rays Bitewing single film 100% 100% Complete series 100% 100% Preventive Services Adult Cleaning 100% 100% Child Cleaning 100% 100% Sealants per tooth 100% 100% Fluoride application with cleaning 100% 100% Space maintainers 100% 100% Basic Services Amalgam filling 2 surfaces 80% 80% Resin filling 2 surfaces, anterior 80% 80% Oral Surgery Extraction exposed root or erupted tooth 80% 80% Extraction of impacted tooth soft tissue 80% 80% *Major Services Complete upper denture 50% 50% Partial upper denture (resin base) 50% 50% Crown Porcelain with noble metal 50% 50% Pontic Porcelain with noble metal 50% 50% Inlay Metallic (3 or more surfaces) 50% 50% Oral Surgery Removal of impacted tooth partially bony 50% 50% Endodontic Services Bicuspid root canal therapy 50% 50% Molar root canal therapy 50% 50% Periodontic Services Scaling & root planing per quadrant 50% 50% Osseous surgery per quadrant 50% 50% *Orthodontic Services 50% 50% Orthodontic Lifetime Maximum $1,000 $1,000 * Coverage Waiting Period: Must be an enrolled member of the plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Access to negotiated discounts: On all PPO Max Plans, members may be eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. Orthodontic coverage is available only to groups with 10 or more eligibles and for dependent children only. OOS Voluntary: If there is a lapse in coverage, members may not re-enroll in the plan for a period of two years from the date of termination. If they are eligible for coverage at that time, they may re-enroll, subject to all provisions of the plan, including, but not limited to, the Coverage Waiting Period. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page 46. For out-of-state employees in all states except: Arkansas, Alaska, Hawaii, Idaho, Maine, Massachusetts, Montana, North Carolina, North Dakota, New Hampshire, New Mexico, South Dakota, Vermont, Wyoming. 27

30 C o n n e c t i c u t p l a n G U I D E Aetna Avenue Life and Disability Overv iew Aetna Life Insurance Company (Aetna) Small Group packaged life and disability insurance or benefits plans include a range of flat-dollar insurance options bundled together in one monthly per-employee rate. These products are easy to understand and offer affordable benefits to help your employees protect their families in the event of illness, injury or death. You ll benefit from streamlined plan installation, administration and claims processing, and all of the benefits of our standalone life and disability products for small groups. Or, simply choose from our portfolio of group basic term life and disability insurance plans. L ife insu r ance We know that life insurance is an important part of the benefits package you offer your employees. That s why our products and programs are designed to meet your needs for: Flexibility Added value Cost-efficiency Experienced support We help you give employees what they re looking for in lifestyle protection, through our selected group life insurance options. And we look beyond the benefits payout to include useful enhancements through the Aetna Life Essentials SM program. So what s the bottom line? A portfolio of value-packed products and programs to attract and retain workers while making the most of the benefits dollars you spend. Giving you (and your employees) what you want Employees are looking for cost-efficient plan features and value-added programs that help them make better decisions for themselves and their dependents. Our life insurance plans come with a variety of features including: Accelerated death benefit Also called the living benefit, the accelerated death benefit provides payment to terminally ill employees or spouses. This payment can be up to 75 percent of the life insurance benefit. Premium waiver provision Employee coverage may stay in effect up to age 65 without premium payments if an employee becomes permanently and totally disabled while insured due to an illness or injury prior to age 60. Optional dependent life This feature allows employees to add optional additional coverage for eligible spouses and children for employers with 10 or more employees. This employee-paid benefit enables employees to cover their spouses and dependent children. Our fresh approach to life With Aetna Life Essentials, your employees have access to programs during their active lives to help promote healthy, fulfilling lifestyles. In addition, Aetna Life Essentials provides for critical caring and support resources for often-overlooked needs during the end of one s life. And we also include value for beneficiaries and their loved ones well beyond the financial support from a death benefit. 28

31 L I F E / D I S A B I L I T Y AD & D Ult r a AD&D Ultra is standardly included with our small group life and disability insurance or benefits plans and provides employees and their families with the same coverage as a typical accidental death and dismemberment plan and then some. This includes extra features at no additional cost to you, such as coverage for education or child-care expenses that make this protection even more valuable. Benefits include: Death Dismemberment Loss of Sight Loss of Speech Loss of Hearing Third-Degree Burns Paralysis Exposure and Disappearance Passenger Restraint and Airbag Education Benefit for Dependent Child and/or Spouse Child Care Benefit Coma Benefit Repatriation of Remains Benefit Total Disability Benefit Disabilit y insu r ance Finding disability insurance or benefits for you and your employees isn t difficult. Many companies offer them. The challenge is finding the right plan one that will meet the distinct needs of your business. Aetna understands this. Our in-depth approach to disability helps give us a clear understanding of what you and your employees need and then helps meet those needs. You ll get the right resources, the right support and the right care for your employees at the right time: Our clinically based disability model ensures claims and duration guidelines are fact-based with objective benchmarks. We offer a holistic approach that takes the whole person into account. We give you 24-hour access to claim information. We provide return-to-work programs to help ensure employees are back to work as soon as it s medically safe to do so. We employ vocational rehabilitation and ergonomic specialists who can help restore employees back to health and productive employment. I nteg r ated He alth and Disabilit y With our Integrated Health and Disability program, we can link medical and disability data to help anticipate concerns, take action and get your employees back to work sooner: Predictive modeling identifies medical members most likely to experience a disability, potentially preventing a disability from occurring or minimizing the impact for better outcomes. Health Insurance Portability and Accountability Act (HIPAA)-compliant so medical and disability staff can share clinical information and work jointly with the employee to help address medical and disability issues. Referrals between health case managers and their disability counterparts help ensure better consistency and integration. The Integrated Health and Disability program is available at no additional cost when a member has both medical and disability coverage from Aetna. For a summary list of Limitations and Exclusions, refer to page 47. Life insurance policies and Disability insurance plans/policies are offered and/or underwritten by Aetna Life Insurance Company (Aetna). 29

32 C o n n e c t i c u t p l a n G U I D E T e r m L i f e P l a n O p t i o n s 2-9 Employees Employees Basic Life Schedule Flat $10,000, $15,000, $20,000, $50,000 Flat $10,000, $15,000, $20,000, $50,000, $75,000, $100,000, $125,000 Class Schedules Not Available Up to 3 classes (with a minimum requirement of 3 employees in each class) the benefit amount of the highest class cannot be more than 5 times the benefit amount of the lowest class Premium Waiver Provision Premium Waiver 60 Premium Waiver 60 Age Reduction Schedule Original Life Amount reduces to 65% at age 65; 40% at age 70; 25% at age 75 Original Life Amount reduces to 65% at age 65; 40% at age 70; 25% at age 75 Accelerated Death Benefit Up to 75% of Life Amount for terminal illness Up to 75% of Life Amount for terminal illness Guaranteed Issue $20, employees $75, employees $100,000 Participation Requirements 100% 100% on non-contributory plans; 75% on contributory plans Contribution Requirements 100% Employer Contribution Minimum 50% Employer Contribution AD&D Ultra AD&D Schedule Matches Life Benefit Matches Life Benefit Additional Features Passenger restraint and airbag, education benefit for your child and/or spouse, child care, repatriation of remains, coma, Total Disability, 365-day covered loss Optional Dependent Term Life Spouse Amount Not Available $5,000 Child Amount Not Available $2,000 Passenger restraint and airbag, education benefit for your child and/or spouse, child care, repatriation of remains, coma, Total Disability, 365-day covered loss D i s a b i l i t y P l a n O p t i o n s Short Term Benefits Plan Option 1 Plan Option 2 Plan Amount Choice of flat $100 increments to a maximum of $500 weekly Benefits Start Accident 1 Day 8 Days Benefits Start Illness 8 Days 8 Days Maximum Benefit Period 26 Weeks 26 Weeks Maternity Benefit Maternity treated same as any other disability but is subject to pre-existing. If pregnant before the effective date, the pregnancy is not covered unless she has prior creditable coverage. Pre-Existing Conditions Rule 3/12 3/12 Actively at Work Rule Applies Applies Other Income Offset Integration N/A N/A Choice of flat $100 increments to a maximum of $500 weekly Maternity treated same as any other disability but is subject to pre-existing. If pregnant before the effective date, the pregnancy is not covered unless she has prior creditable coverage. Other Income Offset Integration Earnings Loss of 20% or more Earnings Loss of 20% or more Definition of Disability Earnings Loss of 20% or more Earnings Loss of 20% or more Class Schedules Up to 3 classes (with a minimum requirement of 3 employees in each class) available for groups of 10 or more employees Up to 3 classes (with a minimum requirement of 3 employees in each class) available for groups of 10 or more employees Life insurance policies and Disability insurance plans/policies are offered and/or underwritten by Aetna Life Insurance Company (Aetna). 30

33 Pac k ag e d L i f e a n d D i s a b i l i t y P l a n O p t i o n s L I F E / D I S A B I L I T Y Basic Life Plan Design Low Option Medium Option High Option Benefit Flat $10,000 Flat $20,000 Flat $50,000 Guaranteed Issue 2-9 Lives Lives $10,000 $10,000 $20,000 $20,000 $20,000 $50,000 Reduction Schedule Employee s Original Life Amount Reduces to 65% at age 65; 40% at age 70; 25% at age 75 Employee s Original Life Amount Reduces to 65% at age 65; 40% at age 70; 25% at age 75 Employee s Original Life Amount Reduces to 65% at age 65; 40% at age 70; 25% at age 75 Disability Provision Premium Waiver 60 Premium Waiver 60 Premium Waiver 60 Conversion Included Included Included Accelerated Death Benefit Up to 75% of benefit; 24 month acceleration Dependent Life Spouse $5,000; Child $2,000 AD&D ULTRA Up to 75% of benefit; 24 month acceleration Spouse $5,000; Child $2,000 Up to 75% of benefit; 24 month acceleration Spouse $5,000; Child $2,000 AD&D Ultra Matches Basic Life Benefit Matches Basic Life Benefit Matches Basic Life Benefit AD&D Ultra Additional Features Seat Belt/Airbag, Education, Child Care, Repatriation, Coma, Total Disability, 365-Day Covered Loss Disability Plan Design Monthly Benefit Flat $500; No offsets Flat $1,000; Offsets are Workers Compensation, any State Disability Plan, and Primary and Family Social Security benefits. Elimination Period 30 days 30 days 30 days Definition of Disability Own Occupation: Earnings loss of 20% or more. Own Occupation: Earnings loss of 20% or more. Benefit Duration 24 months 24 months 60 months Pre-Existing Condition Limitation 3/12 3/12 3/12 First 24 months of benefits: Own Occupation: Earnings Loss of 20% or more; Any reasonable occupation thereafter: 40% earnings loss. Types of Disability Occupational & Non-Occupational Occupational & Non-Occupational Occupational & Non-Occupational Separate Periods of Disability Mental Health/ Substance Abuse 15 days during elimination period 6 months thereafter 15 days during elimination period 6 months thereafter 15 days during elimination period 6 months thereafter Duration same as all other conditions Duration same as all other conditions Duration same as all other conditions Waiver of Premium Included Included Included Other Plan Provisions Eligibility Active Full Time Employees Active Full Time Employees Active Full Time Employees Rate Guarantee 1 year 1 year 1 year Rates PEPM $8.00 $15.00 $27.00 Life insurance policies and Disability insurance plans/policies are offered and/or underwritten by Aetna Life Insurance Company (Aetna). 31

34 C o n n e c t i c u t p l a n G U I D E Aetna Avenue Small Group Underwriting guidel i nes This material is for informational purposes only. It is not intended to be all inclusive. Other policies and guidelines may apply. Note: State and Federal Legislation/ Regulations, including Small Group Reform and HIPAA, take precedence over any and all Underwriting Rules. Exceptions to Underwriting Rules require approval of the Regional Underwriting Manager, except where Head Underwriter approval is indicated. This information is the property of Aetna and its affiliates ( Aetna ), and may only be used or transmitted with respect to Aetna products and procedures, as specifically authorized by Aetna, in writing. C a rve Outs/ E xc luded Cl a ss Union employees, as a class, may be excluded by an employer as not being eligible for coverage. Management carve outs are not permitted. C ensus Data Census data must be provided on all eligible (and COBRA/State Continuation eligible) employees and include name, age/date of birth, date of hire, gender, dependent status, employee work location zip code and residence zip code. Retirees are not eligible. COBR A / State CONTINUAT I ON Eligibilit y COBRA/State Continuation eligibles should be included and noted on the census. Family Health Statements must be provided on COBRA/State Continuation individuals along with the rest of the group. Date COBRA/State Continuation coverage began and the length of eligibility will be required at time of enrollment. Employers with 20 or more employees (full-time and part-time) are required to offer COBRA coverage. Employers with less than 20 employees (full-time and part-time) are required to offer State Continuation. C a se Submission Dates Groups with 1 to 50 eligibles must have all completed paperwork into Aetna Underwriting 5 business days prior to the requested effective date. If not received by this date, the effective date will be moved to the next month. Specific health benefits plans are available for groups of one (1). Please contact your Aetna sales representative or Aetna Small Group Underwriting. Medicare Advantage sales must have all completed paperwork in to Aetna Underwriting 15 business days prior to the requested effective date. If completed paperwork is not received by this date, the effective date will be moved to the next month. 32

35 U N D E R W R I T I N G Dual Produc t Op t i on Minimum of 5 enrolled with 75% participation after spousal or Medicare waivers for all combinations of products. The plan selections are limited to any 2 medical plans. One person must enroll in each plan when a dual option is offered. T r i ple Produc t Op t i on Minimum of 10 enrolled with 75% participation after spousal or Medicare waivers for all combinations of products. The plan selections are limited to any 3 medical plans, 1 of which must be an HSA-compatible plan. One person must enroll in each plan when a triple option is offered. Effec t ive Date The effective date will be the 1st or the 15th of the month. The effective date requested by the employer may be up to 60 days in advance. Medicare Advantage may only be effective on the 1st of the month. When a Medicare Advantage plan and a commercial plan are sold to an employer, the effective dates must coincide (i.e., 1st of the month). Employer Eligibilit y A person, firm, corporation, limited liability company, partnership or association actively engaged in business or self-employed for at least 3 consecutive months, who, on at least 50% of its working days during the preceding 12 months, employed no more than 50 eligible employees, the majority of whom were employed in Connecticut. Organizations must not be formed solely for the purpose of obtaining health coverage. Associations, Taft Hartley groups, Professional Employers Organizations (PEO)/employee leasing firms must be written individually and are not eligible to be combined for purposes of obtaining health coverage. Submission of the most recent UC-5A and Employer Verification Form. If there are employees who have the same last name, provide a W-2 for each employee and the UC-5A should include both individuals listed as separate employees. Employees who have terminated or work part-time should be noted accordingly on the census. Newly hired employees should be written in on the Quarterly Wage and Tax Statement signed by the employer. The underwriter may request payroll in questionable situations. 33

36 C o n n e c t i c u t p l a n G U I D E Single employer groups with multiple employer tax ID numbers will be considered together as long as: One owner controls the majority of each separate business. For example: Business 1 John owns 75% and Mike owns 25% Business 2 John owns 55% and Mike owns 45% Both businesses can be written as one group since John has controlling interest in both companies Businesses with equal controlling interest may be considered if the owners of the company designate an individual to act on behalf of all the groups. A copy of current 1120 S (Schedule K-1 Form) must be provided unless owner is listed on prior carrier bill; and A copy of most recent Quarterly Wage and Tax Statement for all companies must be provided. If employee is a sole proprietor, partner or corporate officer, the Proof of Eligibility Form (see Producer World or contact Underwriting for this form) must be completed and submitted with the following: Sole Proprietor Must submit one of the following: IRS Form 1040C or 1040F IRS Form 1040SE Submit all applicable: Assumed Name Certificate (Fictitious Business Names or DBA) Filed Certificate of Organization (Only required for LLC) Partner Must submit one of the following: IRS Form 1065 (Schedule K-1) IRS Form 1040SE Submit all applicable: State Filed Partnership Agreement Assumed Name Certificate (Fictitious Business Names or DBA) Filed Certificate of Organization (Only required for LLC) Corporate Officer Must submit one of the following: IRS Form 1120, 1120A or 1120W (C-Corp & Personal Service Corp) IRS Form 1120S, K-1 or 1040 ES (S-Corp) Submit all applicable: Filed Certificate of Organization (Only required for LLC) Articles of Incorporation (complete, including name of officers) AND Filed Certification of Qualification (if incorporated in a different state) 34

37 U N D E R W R I T I N G E m p l oy e r F i n a n c i a l C o n d i t i o n s A current carrier bill with billing summary will be required; group must be no more than one month in arrears on payments (i.e., current month only may not yet be paid). Groups that have been terminated for non-payment by Aetna will not be eligible to reapply until 12 months after the date of termination. I n i t i al Premium C hec k The initial premium check is not a binder check and does not bind Aetna to provide coverage. If the request for coverage is denied due to business ineligibility, participation and/or contributions not met, or other permissible reasons, the check will be returned to the employer. An initial premium check equal to one-month premium must accompany application. Checks must be on company check stock (personal checks and cashier s checks are not acceptable). Final R ates Rating will be based on final enrollment. Newly Formed Business A company must have been in business for a minimum of 3 months to be eligible for coverage and must provide the following documentation for consideration: Payroll records or letter from attorney or Certified Public Accountant listing the names of all employees and number of hours worked each week; and Tax ID number. Probat i onary Period The employer decides whether or not to impose a probationary period. The probationary period must be consistently applied to all eligible employees. On-time entrant eligibility date will be the first day of the policy month (1st or 15th of the month) following the waiting period of 0, 30, 60, 90, 120, 150 or 180 days. Changes allowed on anniversary only. Producers Only appropriately licensed Agents/Producers appointed by Aetna may market, present, sell and be paid commission on the sale of Aetna products. All quotes are subject to change based upon additional information that becomes available in the quoting process and during the case submission/installation, including any change in census. Repl ac i ng Other G roup Cover age A copy of the current billing statement that includes the account summary showing the plan is paid to the current premium due date. The employer should be told not to cancel any existing medical coverage until they have been notified of approval. 35

38 C o n n e c t i c u t p l a n G U I D E P R O D U C T S P E C I F I C AT I O N S Product Availability Employer Contributions Employee Eligibility Medical Dental Life/Packaged Life & Disability All plans are available for groups with 2 to 50 eligible employees. May be written standalone or with ancillary coverage as noted in the following columns. Sole Proprietor may only enroll in one of the following: Connecticut Mandated CSEHRP HMO Connecticut Mandated CSEHRP Traditional Choice We strongly recommend in groups with less than 10 eligible lives, that the employer contribute 100% of the employee-only cost or 50% of the total cost of the plan. We strongly recommend in groups with 10 to 50 eligible lives, that the employer contribute at least 50% of employee-only cost or 50% of the total cost of the plan. Eligible employees are those employees who are permanent and work on a full-time basis with a normal work week of at least 30 hours and who have met any authorized waiting period requirements. Coverage must be extended to all employees meeting the above conditions, unless they belong to a union class excluded as the result of a collective bargaining arrangement. Employees who do not meet the definition of a permanent full-time employee will not be eligible (e.g., leased, part-time, temporary, seasonal or substitute employees). Connecticut Small Group reform excludes union employees who are covered by a collective bargaining agreement. 2 eligible employees Standard Dental available with Medical Voluntary Dental Not available 3 to 50 eligible employees Standard and Voluntary Plans available with or without Medical. Orthodontic coverage is available to dependent children only for groups with 10 or more eligible employees with a minimum of five enrolled for both Standard and Voluntary plans. For Standard plans, employers must contribute at least 25% of the total cost of the plan or 50% of the cost of employee only coverage. Coverage will be denied based on inadequate contributions. For Voluntary plans, employers must contribute less than 50% of the cost of employeeonly coverage. Aetna allows zero percent contributory plans. Eligible employees are those employees who are permanent and work on a full-time basis with a normal work week of at least 30 hours and who have met any authorized waiting period requirements. Coverage must be extended to all employees meeting the above conditions, unless they belong to a union class excluded as the result of a collective bargaining arrangement. Employees who do no meet the definition of a permanent full-time employee will not be eligible (e.g., leased, part-time, temporary, seasonal or substitute employees). 2 to 9 eligible employees available only if packaged with Medical. 10 to 25 eligible employees Standard life available either packaged with Medical or Dental. 26 to 50 eligible employees Standard life available either packaged with medical or dental or on a standalone basis. 10 to 50 eligible employees Packaged Life & Disability available either packaged with Medical or Dental or on a standalone basis. Conversion options are not available. 2 to 9 eligible employees 100% of the total cost. 10 to 50 eligible employees at least 50% of the total cost (excluding Optional Dependent Term). Permanent full-time employees who work the minimum hours required for Medical coverage as mandated by the state are eligible for insurance on the effective date of the plan, provided they are actively at work on that date. New employees will be eligible after the completion of a period of continuous active service contractors, stockholders, partners or other outside consultants who are not active, permanent full-time employees are not eligible. Coverage must be extended to all employees meeting the above conditions, unless they belong to a class excluded as the result of conditions pertaining to their employment (e.g., union status or job class). Employees who are both disabled and away from work on the date their insurance would otherwise become effective will become insured on the date they return to active full-time work one full day. Short Term Disability (STD) 2 to 9 eligible employees available only if packaged with Medical. 10 to 25 eligible employees available only if packaged with either Medical or Dental. 26 to 50 eligible employees available only if packaged with Medical or Dental or on a standalone basis. Product packaging rule is a group level requirement. Employees will be able to individually elect STD even if they do not elect Medical coverage. Not available in New York, New Jersey, California, Rhode Island, Hawaii and Puerto Rico. Conversion options are not available. Must be written on a full or primary replacement basis. 2 to 9 eligible employees 100% of the total cost. 10 to 50 eligible employees at least 50% of the total cost. Permanent full-time employees who work the minimum hours required for medical coverage as mandated by the state are eligible for insurance on the effective date of the plan, provided they are actively at work on that date. New employees will be eligible after the completion of a period of continuous active service contractors, stockholders, partners or other outside consultants who are not active, permanent full-time employees are not eligible. Foreign nationals and expatriates are not eligible. Coverage must be extended to all employees meeting the above conditions, unless they belong to a class excluded as the result of conditions pertaining to their employment (e.g., union status or job class). 36

39 P R O D U C T S P E C I F I C AT I O N S U N D E R W R I T I N G Dependent Eligibility Late Applications/Entrant Option Sales Medical Dental Life/Packaged Life & Disability Eligible dependents include an employee s spouse, same sex civil union partners, and domestic partners. Dependent children, as defined in plan documents in accordance with state and federal law, are eligible for medical coverage up to age 26. Individuals cannot be covered as an employee and dependent under the same plan, nor may children eligible for coverage through both parents be covered by both under the same plan. Dependents must enroll in same benefit options as the employee. Eligible dependents include an employee s spouse, same sex civil union partners and domestic partners. Dependent children, as defined in plan documents in accordance with state and federal law, are eligible for dental coverage up to age 26. Individuals cannot be covered as an employee and dependent under the same plan, nor may children eligible for coverage through both parents be covered by both under the same plan. Dependents must enroll in same benefit options as the employee. Dependent children are covered from 14 days up to age 19, or up to 25 if in school (subject to state laws). Incapacitated children can be covered beyond the standard age limit. Eligible dependents include an employee s spouse and unmarried children up to the limiting age of the plan. Individuals cannot be covered as an employee and dependent under the same plan, nor may children eligible for coverage through both parents be covered by both under the same plan. Dependent Life Insurance is available as a separate plan design. Dependents are not eligible for AD&D Ultra. Short Term Disability (STD) Available to employees only. Dependents are not eligible. An employee or dependent who enrolls for coverage more than 31 days from the date first eligible is considered a late enrollee. Applicants without a qualifying life event (i.e., marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.) are subject to the Late Entrant guidelines as follows: Late applicants without a qualifying life event (i.e., marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.) are not allowed and will be deferred to the next plan anniversary date of the group and must reapply for coverage 30 days prior to the group anniversary date. All medical plans must be offered on a full-replacement basis. No other employer sponsored medical plan. Medical Underwriting Not Applicable. Not Applicable. An employee or dependent that enrolls other than within 31 days of first becoming eligible is subject to the Late Entrant provision. Coverage limited to Preventive & Diagnostic services for first 12 months. No coverage for most Basic and Major Services for first 12 months (24 months for Orthodontics). All dental plans must be offered on a full-replacement basis. No other employer sponsored dental plan. An employee or dependent that enrolls for coverage more than 31 days from the date first eligible is considered a late enrollee and may only enroll for coverage 30 days prior to the next plan anniversary date. The applicant will be required to complete an individual health statement/ questionnaire and provide Evidence of Insurability (EOI). Must be written on a full or primary replacement basis. All timely entrants will be issued the Guaranteed Issue amount unless reinstatement or restoration of coverage is requested. Employees wishing to obtain insurance amounts above the Guaranteed Issue amounts will be required to submit Evidence of Insurability (EOI), which means they must complete an individual health statement and may have to submit medical evidence. An employee or dependent that enrolls for coverage more than 31 days from the date first eligible is considered a late enrollee and may only enroll for coverage 30 days prior to the next plan anniversary date. The applicant will be required to complete an individual health statement/ questionnaire and provide Evidence of Insurability (EOI). Must be written on a full or primary replacement basis. All timely entrants will be issued the Guaranteed Issue amount unless reinstatement or restoration of coverage is requested and/or they are late entrants. 37

40 C o n n e c t i c u t p l a n G U I D E P R O D U C T S P E C I F I C AT I O N S Participation Retiree Coverage Medical Dental Life/Packaged Life & Disability For non-contributory plans, 100% participation is required, excluding all valid waivers.* For contributory plans: Groups with 1 to 50 eligible employees 75% participation excluding valid waivers* must enroll in Aetna s plan. Retiree coverage is not available for Medical coverage. For non-contributory plans, 100% participation is required, excluding those with other qualifying Dental coverage. Standard Dental 2 to 3 eligibles 100% participation is required, excluding those with other qualifying existing Dental coverage. 4 to 50 eligibles 75% participation is required, excluding those with other qualifying existing Dental coverage. A minimum of 50% of total eligible employees must enroll in the Dental plan. Voluntary Dental 3 to 50 eligibles 25% participation, excluding those with other qualifying existing Dental coverage or a minimum of 3 enrollees (5 enrollees for orthodontia coverage) whichever is greater is required. Standalone Dental 75% participation is required excluding those with other qualifying Dental coverage. A minimum of 50% of total eligible employees must enroll in the Dental plan. Employees may select coverage for eligible dependents under the Dental plan even if they elected single coverage on the Medical plan or vice versa. Coverage can be denied based on inadequate participation. Retiree coverage is not available for Dental coverage. For non-contributory plans, 100% participation is required. Employees may elect Life or Packaged Life/Disability insurance even if they do not elect Medical coverage, and the group must meet the required participation percentage. If not, then Life or Packaged Life/Disability will be declined for the group. Example: 9 employees, 3 waiving Medical. All 9 must enroll for Life or Packaged Life/Disability. 2 to 9 eligibles 100% participation is required. 10 to 50 eligibles 75% participation is required. COBRA continuees are not eligible for Life. Coverage can be denied based on inadequate participation. Retirees are not eligible for Life or Packaged Life/Disability Insurance coverage. Short Term Disability (STD) For contributory plans: 2 to 9 employees 100% participation is required. 10 to 50 employees 75% participation is required. For non-contributory plans: 100% participation is required. COBRA continuees are not eligible for Disability. Retirees are not eligible for STD coverage. * Valid waivers include spousal/parental group coverage, Medicare, Husky, Champus/ChampVA, Military coverage, Retiree coverage or Association coverage. Individual coverage is not a valid waiver. 38

41 U N D E R W R I T I N G P R O D U C T S P E C I F I C AT I O N S Out-of-State Employees Ineligible Industries Medical Dental Life/Packaged Life & Disability In order for Aetna to accommodate an out-of-state/ situs employee, 51% or more of the employees must be employed in the domiciled state. Any employee residing in a state with an Aetna Managed Choice Network will be eligible to enroll in the Connecticut Managed Choice Health Benefit Plan. Any employee not residing in a state with an Aetna Managed Choice Network will be enrolled in the Connecticut Traditional Choice Indemnity Benefit Plan. Any employee located in Connecticut, New Jersey, New York, Delaware, Maryland, Pennsylvania or Washington, D.C., but not residing in a state with an Aetna Managed Choice Network will be enrolled in the Connecticut Traditional Choice Indemnity Benefit Plan. Employees of Connecticut-based groups who commute to the Connecticut work location from another state may be enrolled in the Connecticut plan(s) offered under live/work rules. All industries are eligible for medical coverage subject to underwriting guidelines. Employees who reside outside of Connecticut, New Jersey and New York are considered outside the situs region. Out-of-State/Situs employees will be offered one of the specific out-of-state/situs dental PPO plans. Employees who fall outside a dental PPO network area will default to a comparable Indemnity plan. Maximum out-of-state/situs employee percentage (and/or number of employees) will agree with the Medical guidelines. The ineligible industry list applies only when Dental is sold standalone or packaged only with Group Insurance. This list does not apply when Dental is sold in combination with Medical. SIC Range SIC Description 7933 Bowling Centers 8611 Business Associations 7911 Dance Studios, Schools Employment Agencies 7999 Misc Amusement and Recreation 8699 Misc Membership Organizations 8999 Misc Services 7991 Physical Fitness Facilities 8811 Private Households Professional Sports Clubs & Producers, Race Tracks Professional Membership Organizations, Labor Unions, Civic Social & Fraternal Organizations, Political Organizations Public Golf Courses, Amusements Membership Sports & Recreation Clubs 8661 Religious Organizations Theatrical Producers, Bands, Orchestras, Actors Basic Term Life: all industries are eligible. Packaged Life/Disability: the following industries are not eligible: SIC Range SIC Description Mining Explosives, Bombs & Pyrotechnics Asbestos Products Primary Metal Industries Fire Arms & Ammunition 5921 Liquor Stores 6211 Security Brokers 6531 Real Estate Agents 7381 Detective Services Automotive Repairs & Services Motion Picture/ Amusement & Recreation Offices & Clinics of Medical Doctors Membership Associations Service Private Households 9999 Nonclassified Establishments Short Term Disability (STD) SIC Range SIC Description Mining Explosives, Bombs & Pyrotechnics Asbestos Products Primary Metal Industries Fire Arms & Ammunition 5921 Liquor Stores 6211 Security Brokers 6531 Real Estate Agents 7381 Detective Services Automotive Repairs & Services Motion Picture/ Amusement & Recreation Offices & Clinics of Medical Doctors Membership Associations Service Private Households 9999 Nonclassified Establishments 39

42 C o n n e c t i c u t p l a n G U I D E P R O D U C T S P E C I F I C AT I O N S Actively-at-Work Medical Dental Life/Packaged Life & Disability Employees who are both disabled and away from work on the date their insurance would otherwise become effective will become insured on the date they return to active full-time work one full day. Short Term Disability (STD) Actively-at-Work employees who are both disabled and away from work on the date their insurance would otherwise become effective will become insured on the date they return to active full-time work one full day. Continuity of Coverage (No Loss/No Gain) The employee will not lose coverage due to a change in carriers. This protects employees who are not actively at work during a change in insurance carriers. If an employee is not actively at work, Aetna will waive the actively-atwork requirement and provide coverage, except no benefits are payable if the prior plan is liable. The employee will not lose coverage due to a change in carriers. This protects employees who are not actively at work during a change in insurance carriers. If an employee is not actively at work, Aetna will waive the actively-atwork requirement and provide coverage, except no benefits are payable if the prior plan is liable. 40

43 U N D E R W R I T I N G DENTAL ONLY For Standalone Dental Sales Only Employer Eligibility will require the completion of the Employer Verification Form. The Quarterly Wage & Tax for Standalone dental is not required. Submission of an employer roster is required. Full-T ime Hours Full-time hour guideline will agree with the Medical guidelines. Open Enrollment Open enrollments are prohibited. An employee or dependent can enroll at any time but is subject to the Dental Late Entrant provision if enrollment occurs other than within 31 days of first becoming eligible unless a qualifying life event has occurred or the enrollee is less than age 5. Cover age Wa i t i ng Period For Major and Orthodontic Services, must be an enrolled member of plan for 1 year before becoming eligible (not applicable to DMO). The coverage waiting period is waived separately for Major or Orthodontic Services for employees who were covered by the group s immediately preceding Dental plan. To waive the waiting period for Orthodontic Services, the group s immediately preceding plan must have included orthodontic coverage. To waive the waiting period for Major Services, the group s immediately preceding plan must have included Major Services. Example: Prior Major coverage but no Orthodontic coverage. Aetna plan has coverage for both Major and Orthodontics. The waiting period is waived for Major Services but not for Orthodontic Services. Reinstatement For Voluntary plans, members who were once enrolled then terminated their coverage by discontinuing their contributions may not re-enroll for a period of 24 months. All coverage rules will apply from the new effective date including, but not limited to, the Coverage Waiting Period. Produc t Pac k ag i ng DMO cannot be sold as standalone and must be packaged with any PPO option as Dual Option. PPO plans can be sold standalone or packaged with DMO as a Dual Option or Freedom-of-Choice. Freedom-of-Choice cannot be packaged with any other option. It must be the only sold plan. Forms The same enrollment applications are required for new business medical. 41

44 C o n n e c t i c u t p l a n G U I D E L IFE ONLY Full-T ime Hours Full-time hour guideline will agree with the Medical guidelines. Contr ac tual Underw r i t i ng Open enrollments are prohibited. Life is bundled with Medical at the employer level, not the employee level. Therefore, a subscriber within a given group can waive Medical Underwriting coverage and still enroll for Life/AD&D. Life coverage can be offered to sole proprietorships, partnerships or corporations. Associations, Taft-Hartley groups, employee leasing firms and closed groups are not eligible for coverage and must be written individually. Must meet the qualifications of a small business. The same employer eligibility guidelines that apply to medical will apply to the life coverage. Medic al Underw r i t i ng New Business Medical Evaluation At new business time, any dependents enrolling for coverage are Guaranteed Issue and not subject to Evidence of Insurability (EOI). Employees wishing to obtain insurance amounts above the Guaranteed Issue amounts listed below will be required to submit EOI, which means they must complete an individual health statement/questionnaire. Case Size Basic Term Life Amount 2-9 eligible employees $20, eligible employees $75, eligible employees $100,000 Only those employees who have an unacceptable medical condition will be reduced to the Guaranteed Issue amount. The rest of the employees will be issued the higher amount if they medically qualify. Example: Applying for $50, year-old male Heart attack 6 months ago, no surgery Reduced to $20,000 Life. All other employees will be issued $50,000. In those states that have a case size differential for completing different sections of the health questions, the determining factor is based on the number of enrolled employees and not the number of eligible employees. 42

45 U N D E R W R I T I N G E v idence of I nsu r abilit y ( EO I ) Evidence of Insurability (evidence of good health) is required when one or more of the following conditions exist: Life amounts are above the maximum Guaranteed Issue amount. Late Entrant coverage is not requested within 31 days of eligibility for contributory coverage. Reinstatement or restoration of coverage is requested. New coverage is requested during the anniversary period. Coverage is requested outside of the employer s anniversary period due to qualifying life event (marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.). Dependent coverage option was initially refused by employee but requested later. The dependent would be considered a late entrant and subject to EOI, and may be declined for medical reasons. New Hires New hires wishing to obtain insurance amounts above the Guaranteed Issue amounts will be required to submit Evidence of Insurability (EOI), which means they must complete a medical questionnaire. If the employee has an unacceptable medical condition, the employee will be reduced to the Guaranteed Issue amount. Full-T ime Hours Full-time hour guideline will agree with the Medical guidelines. Gua r anteed Issue No Medic al Underw r i t i ng Coverage is Guaranteed Issue and does not require an employee to answer any medical questions or submit to medical records or a medical exam unless: Reinstatement or restoration of coverage is requested, and/or Coverage is not requested within 31 days of eligibility for contributory coverage, and the employee is a late entrant. Employer Eligibilit y The same employer eligibility guidelines that apply to medical apply to STD coverage. Underwriters may require IRS forms or other documents to demonstrate proof of business and employee eligibility. The employer must have Workers Compensation coverage. Groups are ineligible for coverage if 60% or more of eligible employees or 60% or more of eligible payroll are for employees over 50 years old. 43

46 C o n n e c t i c u t p l a n G U I D E L imitat i ons and exc lusions These plans do not cover all health care expenses and include exclusions and limitations. Employers and members should refer to their plan documents to determine which health care services are covered and to what extent. Medic al The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased. Groups of one will be offered the following Connecticut State Mandated Plans pursuant to Connecticut state law: CSEHRP HMO or CSEHRP TC. For plan design benefit descriptions, please refer to Aetna s Producer World website at or contact your licensed agent or Aetna Sales Representative. Aetna Open Access QPOS plan Services and supplies that are generally not covered include, but are not limited to: All medical and hospital services not specifically covered in, or which are limited or excluded by your plan documents, including costs of services before coverage begins and after coverage terminates Cosmetic surgery Custodial care Dental care and dental X-rays Donor egg retrieval Experimental and investigational procedures (except for coverage for medically necessary routine patient care costs for members participating in a cancer clinical trial) Immunizations for travel or work Implantable drugs and certain injectable drugs including injectable infertility drugs Infertility services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services unless specifically listed as covered in your plan documents Nonmedically necessary services or supplies Orthotics Over-the-counter medications and supplies Radial keratotomy or related procedures Reversal of sterilization Services for the treatment of sexual dysfunction or inadequacies including therapy, supplies or counseling Special duty nursing Therapy or rehabilitation other than those listed as covered in the plan documents 44

47 U N D E R W R I T I N G Aetna Open Access Managed Choice plan and Traditional Choice plan Services and supplies that are generally not covered include, but are not limited to: All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents Charges related to any eye surgery mainly to correct refractive errors Cosmetic surgery, including breast reduction Custodial care Dental care and X-rays Donor egg retrieval Experimental and investigational procedures Immunizations for travel or work Infertility services, including, but not limited to, artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan documents Nonmedically necessary services or supplies Orthotics Over-the-counter medications and supplies Reversal of sterilization Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies or counseling Special duty nursing 45

48 C o n n e c t i c u t p l a n G U I D E L imitat i ons and exc lusions Dental Listed below are some of the charges and services for which these dental plans do not provide coverage. For a complete list of exclusions and limitations, refer to plan documents. Dental services or supplies that are primarily used to alter, improve or enhance appearance Experimental services, supplies or procedures Treatment of any jaw joint disorder, such as temporomandibular joint disorder Replacement of lost, missing or stolen appliances and certain damaged appliances Those services that Aetna defines as not necessary for the diagnosis, care or treatment of a condition involved Specific service limitations DMO Plans: Oral exams (4 per year) PPO Plans: Oral exams (2 routine and 2 problem-focused per year) All Plans: Bitewing X-rays (1 set per year) Complete series X-rays (1 set every 3 years) Cleanings (2 per year) Fluoride (1 per year; children under 16) Sealants (1 treatment per tooth, every 3 years on permanent molars; children under 16) Scaling & root planing (4 quadrants every 2 years) Osseous surgery (1 per quadrant every 3 years) All other limitations and exclusions in your plan documents. Disability Limitations and Exclusions * These do not apply if the loss is caused by an infection that results directly from the injury or surgery needed because of the injury. The injury must not be one that is excluded by the terms of the contract. 46

49 U N D E R W R I T I N G AD & D Ult r a This coverage is only for losses caused by accidents. No benefits are payable for a loss caused or contributed to by: A bodily or mental infirmity A disease, ptomaine or bacterial infection* Medical or surgical treatment* Suicide or attempted suicide (while sane or insane) An intentionally self-inflicted injury A war or any act of war (declared or not declared) Commission of or attempt to commit a criminal act Voluntary use of any controlled substance, as defined in Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, as now or hereafter amended; unless as prescribed by a physician Use of alcohol or intoxicants, an accident in which the blood alcohol level of the operator of a motor vehicle meets or exceeds the level at which intoxication would be presumed under the law of the state where the accident occurred shall be deemed to be caused by the use of alcohol Intended or accidental contact with nuclear or atomic energy by explosion and/or release Air or space travel, this does not apply if a person is a passenger, with no duties at all, on an aircraft being used only to carry passengers (with or without cargo) Disabilit y No benefits are payable if the disability: Is due to intentionally self-inflicted injury (while sane or insane) Results from you committing, or attempting to commit, a criminal act Is due to insurrection, rebellion or taking part in a riot or civil commotion Is due to war or any act of war (declared or not declared) Is not a non-occupational disease (STD only) Is not a non-occupational injury (STD only) Results from driving an automobile while intoxicated. ( Intoxicated means: the blood alcohol level of the driver of the automobile meets or exceeds the level at which intoxication would be presumed under the law of the state where the accident occurred.) On any day during a period of disability that a person is confined in a penal or correctional institution for conviction of a criminal or other public offense, the person will not be deemed to be disabled and no benefits will be payable. No benefit is payable for any disability that occurs during the first 12 months of coverage and is due to a pre-existing condition for which the member was diagnosed, treated or received services, treatment, drugs or medicines three (3) months prior to coverage effective date. 47

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52 Aetna Avenue Your Destination for Small Business Solutions This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits may vary by location. Health/Dental benefits, health/dental insurance, life and disability insurance plans/policies contain exclusions and limitations. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Plan features and availability may vary by location and group size. Aetna HealthFund HRAs are subject to employerdefined use and forfeiture rules and are unfunded liabilities of your employer. Fund balances are not vested benefits. Investment services are independently offered through HealthEquity, Inc. Discount programs provide access to discounted prices and are NOT insured benefits. The member is responsible for the full cost of the discounted services. Plan for Your Health is a public education program from Aetna and The Financial Planning Association. Providers are independent contractors and not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Not all health, dental and disability services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features are subject to change. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna s Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. The Aetna Personal Health Record should not be used as the sole source of information about the member s medical history. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to CT (6/10) 2010 Aetna Inc.