Important information about the Summary of Benefits and Coverage

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Janel Norris
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1 l Important information about the Summary of Benefits and Coverage Enclosed is/are your Summary of Benefits and Coverage (SBC) document(s) for your Aetna medical coverage(s). The SBC is a requirement of the Affordable Care Act (ACA). We share with you the responsibility of generating and delivering this mandated document to your plan participants and are providing information to assist you in meeting these obligations. Please Distribute the SBC(s) to your plan participants and beneficiaries We are generating and releasing to you SBCs for your insured medical plans. As the employer, you are best positioned to distribute SBCs to your employees and their dependents. We are relying on you to distribute them to your plan participants and beneficiaries (members and potential members) in the required timeframe for each scenario outlined in the regulation. Here is a summary of the events that trigger the requirement for production and distribution of the SBC(s). Event Trigger Upon Plan Renewal on or after 9/23/2012 Timeframe to deliver SBC to members and potential members Include SBC: 1. With enrollment / application materials; or 2. If renewal is automatic, then within 30 calendar days before 1st day of the new policy effective date. NOTE: For insured plans with a policy that is not finalized 30 days prior to the first day of the new policy year, the date is as soon as practicable; specifically, within 7 business days after the start of the new policy, or within 7 business days after the receipt of written confirmation of intent to renew whichever is earlier. Open Enrollment beginning on or after 9/23/2012 Include SBC with enrollment application materials; or if enrollment materials are not distributed, no later than the first day of the enrollment period. Upon request of SBC or summary information about health insurance coverage Newly Eligible Deliver the SBC within 7 business days of the request. Aetna will support requests for copies of SBCs received from active members enrolled in a plan. Deliver the SBC:

2 l With enrollment/application materials, or If enrollment materials are not distributed, no later than the first day of the employee s/dependent s eligibility to enroll Special Enrollee (HIPAA) Material Modifications of Benefits Deliver the SBC no later than 90 calendar days from enrollment. If changes in coverage information impacts the content of the SBC after the first day of coverage (off-renewal), send a Notice of Material Modification (can be in form of a revised SBC) to members no later than 60 calendar days before the effective date of the coverage change(s). Aetna will provide you with an updated SBC or Notice to support the communication of a material modification. Together, we can work to comply and avoid penalties It is important that we work together to comply with the law. Insurance carriers and plan sponsors are subject to potential penalties, so timely delivery of the material is important. Willful failure to meet and track the above distribution requirements will subject both the insurer (Aetna) and plan sponsor (you) to potential fines of up to $1,000 per plan participant or beneficiary per failure. There are also separate penalties that may apply that are not specific to the SBC regulation but may be imposed for failure to comply with certain federal requirements. We re here to help with this important requirement Please don t hesitate to call your Aetna account representative or broker if you have questions. We have created letter templates to help you communicate the Summary of Benefits and Coverage to your plan participants. You can download them at This is just a summary of the requirements. For the full list of events, timeframes, distribution requirements and information on the regulations, please review the regulations at the HHS website:

3 l Now there s an easier way for you to share the Summary of Benefits and Coverage As you know the Summary of Benefits and Coverage (SBC) document is a requirement of the Affordable Care Act (ACA). Manage benefits online ebusiness is our secure employer website. It s your gateway to online, hassle-free maintenance of your Aetna plan. Once you register you ll have an online way to share the SBC with your plan participants. Plus all the tools you need to manage your benefits online are available 24/7/365! Simple, online steps to get the SBC If you haven t registered for ebusiness yet, call us at If you are already registered for ebusiness, log in at Then follow the steps below to download and print the SBC. 1. After you log in search and click on the record of any employee who has medical benefits. 2. Click the "Benefits tab and then click on Open Enrollment. 3. Next click on the "Edit" button under the medical section. 4. To download or print the SBC simply click the "Summary Benefits and Coverage (SBC)" hyperlink beneath the plan name. Together we can work to comply and avoid penalties Please remember to follow these easy steps to access the SBC documents. It s important that we work together to comply with the law. We re here to help with this important requirement If you have any questions, please call your broker or the phone number on your bill. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, in cluding Aetna Life Insurance Company and its affiliates (Aetna) Aetna Inc (9/12)

4 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall In-network: Individual $1,500 / Family You must pay all the costs up to the deductible amount before this plan $3,000; Out-of-network: Individual $3,000 / deductible? begins to pay for covered services you use. Check your policy or plan Family $6,000. Does not apply to in-network document to see when the deductible starts over (usually, but not always, office visits, emergency care, urgent care, January 1st). See the chart starting on page 2 for how much you pay for preventive care and prescription drugs. covered services after you meet the deductible. Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn't cover? No. Yes. In-network: Individual $6,350 / Family $12,700; Out-of-network: Individual $12,700 / Family $25,400. Premiums, balance-billed charges, penalties for failure to obtain pre-authorization for services and health care this plan doesn't cover. No. Yes. For a list of in-network providers, see or call No. Yes. You don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don't count toward the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn't cover are listed on page 5. See your policy or plan document for additional information about excluded services. Page 1 of 8

5 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven't met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments, and coinsurance amounts. Common Medical Event If you visit a health care provider's office or clinic If you have a test Services You May Need Use an In-Network Use an Out-Of-Network Limitations & Exceptions Primary care visit to treat an injury or $30 copay per visit, illness Specialist visit $60 copay per visit, Other practitioner office visit $60 copay per visit, for Coverage is limited to 20 visits for for chiropractic care chiropractic care. chiropractic care Preventive care /screening /immunization No charge Age and frequency schedules may apply. Diagnostic test (x-ray, blood work) Lab: $30 copay per visit, deductible waived; X-ray: $60 copay per visit, Imaging (CT/PET scans, MRIs) Precertification required for out-of-network Page 2 of 8

6 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at macy-insurance/indi viduals-families If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Services You May Need Preferred generic drugs Preferred brand drugs Non-preferred generic, brand and specialty drugs Preferred specialty drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fee Use an In-Network Use an Out-Of-Network $15 copay (retail), $30 Not covered copay (mail order) $50 copay (retail), $100 Not covered copay (mail order) up to Not covered a max $500 copay (retail); 50% coinsurance up to a max $1,000 copay (mail order). up to Not covered a max $300 copay for up to a 30 day supply OP Hospital: 40% coinsurance; Freestanding facility: $250 copay per visit, $250 copay per visit, $50 copay per visit, $50 copay per visit, Limitations & Exceptions Covers up to a 30-day supply (retail or mail order prescription); day supply (retail or mail order prescription). No coverage for day supply out-of-network. Applicable cost share plus difference (brand minus generic cost) applies for brand when generic available. No charge for preferred generic FDA-approved women's contraceptives in-network. Precertification and step therapy required. Copay is waived if admitted. OON ER services cost-share same as in-network. No coverage for non-emergency care. OON cost-share same as in-network. No coverage for non-urgent care. Precertification required for out-of-network Page 3 of 8

7 Common Medical Event If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs Services You May Need Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services Use an In-Network $60 copay per visit, $60 copay per visit, Use an Out-Of-Network Limitations & Exceptions Precertification required for out-of-network Precertification required for out-of-network Prenatal and postnatal care Prenatal: No charge; Postnatal: 30% coinsurance Delivery and all inpatient services Precertification required for out-of-network Home health care Rehabilitation services Coverage is limited to 60 visits PT/OT/ST combined. Benefit limits are shared between rehabilitation and habilitation services. Habilitation services Coverage is limited to 60 visits PT/OT/ST combined. Benefit limits are shared between rehabilitation and habilitation services. Skilled nursing care Coverage is limited to 90 days. Precertification required for out-of-network Page 4 of 8

8 Common Medical Event If your child needs dental or eye care Services You May Need Use an In-Network Use an Out-Of-Network Limitations & Exceptions Durable medical equipment Hospice service Precertification required for out-of-network Eye exam $60 copay per visit, Coverage is limited to 1 routine exam per 12 months. Glasses Preferred: No charge; Coverage is limited to 1 pair glasses (lenses Non-preferred: 50% and frames) or contacts per 12 months. coinsurance Dental check-up No charge, Coverage is limited to 2 visits per year. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.) Acupuncture Cosmetic surgery Dental care (Adult) Infertility treatment Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing Routine foot care Weight loss programs Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.) Bariatric surgery Chiropractic care - limited to 20 visits Hearing aids - limited to 1 hearing aid per ear per year Routine eye care (Adult) - limited to 1 routine exam per 12 months Page 5 of 8

9 Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact us by calling the toll free number on your Medical ID Card. You may also contact the Department of Labor's Employee Benefits Security Administration at EBSA (3272) or You may also contact your State Department of Insurance at (800) , Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage". This plan or policy does provide minimum essential coverage. Does this Coverage Provide Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' Para obtener asistencia en Español, llame al To see examples of how this plan might cover costs for a sample medical situation, see the next page Page 6 of 8

10 Coverage Examples About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don't use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care also will be different. See the next page for important information about these examples. Amount owed to providers: $7,540 Plan pays: $4,770 Patient pays: $2,770 Sample care costs: Hospital charges (mother) Routine obstetric care Hospital charges (baby) Anesthesia Laboratory tests Prescriptions Radiology Vaccines, other preventative Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total Having a baby (normal delivery) $2,700 $2,100 $900 $900 $500 $200 $200 $40 $7,540 $1,500 $20 $1,100 $150 $2,770 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays: $2,920 Patient pays: $2,480 Sample care costs: Prescriptions Medical equipment and Supplies Office Visits and Procedures Education Laboratory tests Vaccines, other preventative Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total $2,900 $1,300 $700 $300 $100 $100 $5,400 $1,500 $720 $180 $80 $2,480 Note: Your plan may have both copays and coinsurance for covered services; if so, these examples use copays only. Your costs may be higher. Page 7 of 8

11 Coverage Examples Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don't include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren't specific to a particular geographic area or health plan. The patient's condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn't covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different, based on your doctor's advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can't use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you'll find the same Coverage Examples. When you compare plans, check the "Patient Pays" box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you'll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Page 8 of 8

TX Aetna Classic 5000

TX Aetna Classic 5000 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthreformplansbc.com or by calling 855-632-6274. Important