Aetna Avenue Your Destination for Small Business Solutions TENNESSEE PLAN GUIDE PLANS EFFECTIVE OCTObEr 1, 2010 For businesses with 2 50 eligible employees 14.02.970.1-TN (10/10)
T E N N E S S E E p l a n g u i d e Health care is a journey Aetna AvENue is the way in this guide: 2 Small business commitment 3 Benefits for every stage of life 4 Medical overview 7 Managing health care expenses 8 Medical plan options 12 Dental overview 14 Dental plan options 20 Life & disability overview 22 Life plan options 23 Life & disability plan options 24 Underwriting guidelines 28 Product specifications 34 Limitations and exclusions 38 Group enrollment checklist 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 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 insurance plans. Health/dental insurance plans, life and disability insurance plans are offered, underwritten and/or administered by Aetna Life Insurance Company (Aetna).
CHOICE 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. Employees have access to a wide network of doctors and other providers ensuring that they have a choice in how they receive their health care. Medical plans supporting members on their health care journey Traditional plans 100% plans Consumer-directed health plans HSA-compatible plans Dental, life and disability plans providing valuable protection PPO Preventive Basic term life insurance Packaged life and disability plans EASE 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. 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. Ready on day-one making it work for your employees Once employees are members of the Aetna health benefits and health insurance plans, they ll have access to our various tools and resources to help them use the plans effectively from the start. Aetna Navigator our online resource for employers, members and providers Look up rates for providers, facilities and hospitals for common services and treatments Track medical claims online Discount programs for vision, dental and other health care Personal Health Record providing a complete picture of health Simple Steps To A Healthier Life, an online health and wellness program Temporary ID cards available for members to print as needed REPUTATION In business it s everything Your reputation is important to your business. At Aetna, our reputation is just as important. With 150 years of experience, we value our name, products and services and focus on delivering the right solution for your small business our reputation depends upon it. Our account executives, underwriters and customer service representatives are committed to providing your small business the valuable service it deserves. 1 M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G
T E N N E S S E E 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 2 50 employees and our insurance benefits programs are designed to work for this size group. We ll work with you to determine the right plans for your business and assist you through implementation. 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 Traditional Plans (MC OA 10-05, MC 10-06) Consumer-Directed Plans (MC OA 10-07) HSA-Compatible Plans (MC OA 10-22) 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 HSA-Compatible Plans (MC OA 10-21, MC 10-22) Consumer Directed Plans (MC OA 10-07) Traditional benefits plans Limiting the financial impact on employees You might be a Traditionalist These plans fit Traditional Plans (MC OA 10-01, MC OA 10-02, MC 10-03, MC 10-04) 2
YoUNG SINGLES Consumer-directed health plans HSA-compatible plans YoUNG FAMILIES Traditional plans E STABLISHED FAMILIES Consumer-directed health plans Traditional plans 100% Plans E MPTY NESTERS Consumer-directed health plans HSA-compatible plans HEALTH INSURANCE BENEFITS FoR EvERY STAGE of LIFE 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. EMPTY 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. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 3
T E N N E S S E E p l a n g u i d e Aetna Avenue Medical OverviEW Aetna Open Access Managed Choice plan provider network* Available in these Tennessee counties: Anderson Bedford Benton Bledsoe Blount Bradley Campbell Cannon Carroll Carter Cheatham Chester Claiborne Cocke Coffee Crockett Davidson Decatur Dekalb Dickson Dyer Gibson Grainger Greene Fayette Franklin Giles Grundy Hamblen Hamilton Hancock Hardeman Hardin Hawkins Haywood Henderson Henry Houston Humphreys Jefferson Johnson Knox Lake Lauderdale Lawrence Lewis Lincoln Loudon Macon Madison Marion Marshall Maury McMinn McNairy Meigs Montgomery Moore Morgan Obion Roane Robertson Rutherford Scott Sequatchie Sevier Shelby Smith Stewart Sullivan Sumner Tipton Trousdale Unicoi Union Van Buren Warren Washington Weakley Williamson Wilson WellNESS on us SM Wellness for employees means a healthier business for employers. Our small business health benefits and insurance plans in Tennessee offer $0 copays in-network for in-network eye exams on top of $0 copays for in-network preventive care! It s one more way for us to help employees get a step closer to better health. See what employees can get for $0: Immunizations $0 copay Routine vision exams Routine physicals Child wellness visits Routine mammogram Routine ob/gyn visits Product Name Aetna Open Access Managed Choice (MC OA) Traditional Choice (Indemnity) $0 copay $0 copay $0 copay $0 copay $0 copay Product Description PCP Required Referrals Required Network Managed Choice members can access No No Managed any recognized provider for covered Choice services without a referral. Each time POS (Open members seek health care, they have Access) 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 No No N/A 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 subject to change. 4
WHAT IS SIMPLY SAVINGS? Simply Savings* is the Aetna suite of plans designed specifically for small businesses. Simply Savings offers reduced minimum participation and employer contribution requirements. Simply Savings offers the following advantages: Lower participation and contribution requirements Value plans have lower participation and contribution requirements, except when offered with a non-simply Savings plan.** Greater employee choice Employers can offer up to three of the Simply Savings plans. Flexibility and affordability By choosing a Simply Savings plan, employers are now able to offer benefits to help meet the needs of their employees. S I M P LY S AV I N G S Total freedom Aetna is committed to providing solutions to help meet the needs of small businesses. Employers can now offer quality coverage at affordable prices. Easy administration Setting up this program is simple: 1. The employer chooses up to three of the Simply Savings plans to offer on the Employer Application. 2. The employer chooses how much to contribute. 3. Each employee chooses the plan that s right for him or her. Target audience Small businesses Simply Savings Plan Available MC OA 10-06 MC OA 10-07 MC OA 10-22 Plan choices Up to 3 of the Simply Savings plans Minimum participation 4 or more enrolled employees Employer contribution 25% of the employee premium or $50 per employee Employee participation 50% * Available with four or more enrolled employees. ** If an employer chooses a Simply Savings plan to offer with a non-simply Savings plan, the standard participation and contribution requirements on the non-simply Savings plan will apply to both plans offered. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 5
T E N N E S S E E p l a n g u i d e Administrative fees FEE DESCRIPTION HSA FEE Initial Set-Up $0 Monthly Fees $0 POP* Initial Set-Up** $150 Renewal $75 HRA and FSA*** Initial Set-Up 2 25 Employees $350 26 50 Employees $450 Renewal Fee Monthly Fees Additional Set-Up Fee for stacked plans (those electing an Aetna HRA and FSA simultaneously) Participation Fee for stacked participants 50% of the initial set-up fee $5.00 per participant $150 $9.75 per participant Minimum Fees 0 25 Employees $10 per month minimum 26 50 Employees $50 per month minimum TRA Annual Fee $350 Transit Monthly Fees $4.25 per participant Parking Monthly Fees COBRA Annual Fee 20 50 Employees Monthly Fee $3.15 per participant $50 $0.85 per employee HealTH ReimbuRSEmENT arrangement (HRA) The Aetna HealthFund HRA combines the protection of a deductible-based health plan with a health fund that pays for eligible health care services. The member cannot contribute to the HRA, and employers have control over HRA plan designs. 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. COBRA administration 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. 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. *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. Initial set-up fee for HRA is waived. 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 subject to change. Aetna reserves the right to change any of the above fees and to impose additional fees upon prior written notice. 6
A WAY to MANAGE HEALTH AND HEALTH CARE expenses HEALTH SavINGS ACCoUNT (HSA) No set-up or administrative fees The Aetna HealthFund HSA, when coupled with a HSA-compatible highdeductible health benefits and health insurance plan, is a tax-advantaged savings account. Once enrolled, account contributions can be made by the employee and/or employer. The HSA can be used to pay for qualified expenses tax free. H S A 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 MEMBER S HSA PLAN 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% M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 7
T E N N E S S E E p l a n G U I D E T E N N E S S E E ( 2-5 0 E m p l o y E E S ) PLAN OPTIONS TN MCOA 10-01 TN MCOA 10-02 TN MCOA 10-03 TN MCOA 10-04 Lifetime Maximum Unlimited Unlimited Unlimited Unlimited IN-NETWORK SERVICES Coinsurance 80% 80% 70% 80% Annual Deductible: Individual/Family $500 / $1,000 $1,000 / $2,000 $1,000 / $2,000 $1,500 / $3,000 Type of Deductible Embedded Embedded Embedded Embedded Annual Out-of-Pocket (OOP): Individual/Family (Deductible applies to OOP) Wellness On Us SM $2,500 / $5,000 $3,000 / $6,000 $4,000 / $8,000 $3,500 / $7,000 Preventive Care, including annual Adult Physicals, Well-Women Visits, Mammograms, Colorectal Cancer Screening and other preventive care services Well-Child Care (Age/Frequency schedules apply, includes coverage for immunizations) $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Vision Screening Services (1 time every 24 months) $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Prescription Lens Allowance $125 every 24 months $125 every 24 months $125 every 24 months $125 every 24 months Physician Services Primary Care Physician Office visit $25, deductible waived $25, deductible waived $30, deductible waived $25, deductible waived Specialist Office Visit $50, deductible waived $50, deductible waived $60, deductible waived $50, deductible waived Mental Health Outpatient (25 visits per year) $50, deductible waived $50, deductible waived $60, deductible waived $50, deductible waived Inpatient Services Hospital Inpatient 80%, deductible applies 80%, deductible applies 70%, deductible applies 80%, deductible applies Mental Health Inpatient (30 days per year) 80%, deductible applies 80%, deductible applies 70%, deductible applies 80%, deductible applies Outpatient/Other Services Diagnostic Lab $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Diagnostic X-ray $50, deductible waived $50, deductible waived $60, deductible waived $50, deductible waived Diagnostic Complex Imaging (CAT, MRI, MRA/MRS and PET scans) 80%, deductible applies 80%, deductible applies 70%, deductible applies 80%, deductible applies Outpatient Surgery 80%, deductible applies 80%, deductible applies 70%, deductible applies 80%, deductible applies Emergency Room (Copay waived if admitted) $200, deductible waived $200, deductible waived $250, deductible waived $200, deductible waived Urgent Care $50, deductible waived $50, deductible waived $75, deductible waived $50, deductible waived Ambulance (Emergency transport) 80%, deductible applies 80%, deductible applies 70%, deductible applies 80%, deductible applies Durable Medical Equipment ($3,000 maximum per year) Outpatient Rehabilitative Therapy (30 visits per year, combined with Chiropractic Services) Chiropractic Services (30 visits per year, combined with Outpatient Rehabilitative Therapy) 80%, deductible applies 80%, deductible applies 70%, deductible applies 80%, deductible applies 80%, deductible applies 80%, deductible applies 70%, deductible applies 80%, deductible applies 80%, deductible applies 80%, deductible applies 70%, deductible applies 80%, deductible applies PHARMACY Retail Pharmacy Copay Mail-Order Drugs (MOD) (Available at 2X copay for a 31-90 day supply) $15 / $45 / $65 $15 / $45 / $65 $15 / $45 / $65 $15 / $45 / $65 Self-Injectable Drugs ($30 minimum, $120 maximum copay) OUT-OF-NETWORK (oon) SERVICES 30% 30% 30% 30% Coinsurance 50% 50% 50% 50% Annual Deductible: Individual/Family $1,500 / $3,000 $2,000 / $4,000 $2,000 / $4,000 $3,000 / $6,000 Annual Out-of-Pocket (OOP): Individual/Family (Deductible applies to OOP) $5,000 / $10,000 $4,000 / $8,000 $5,000 / $10,000 $6,000 / $12,000 Emergency Room Paid as In-Network Benefits Paid as In-Network Benefits Paid as In-Network Benefits Paid as In-Network Benefits Ambulance (Emergency transport) All Other Services 50%, deductible applies 50%, deductible applies 50%, deductible applies 50%, deductible applies Retail Pharmacy 70% after copay 70% after copay 70% after copay 70% after copay See page 11 for footnotes. 8
T E N N E S S E E ( 2-5 0 E M P L o Y E E S ) PLAN OPTIONS TN MCOA 10-05 TN MCOA 10-06 TN MCOA 10-07 Lifetime Maximum Unlimited Unlimited Unlimited IN-NETWORK SERVICES Coinsurance 80% 70% 100% Annual Deductible: Individual/Family $2,500 / $5,000 $3,000 / $6,000 $10,000 / $10,000 Type of Deductible Embedded Embedded Embedded Annual Out-of-Pocket (OOP): Individual/Family (Deductible applies to OOP) Wellness On Us SM Preventive Care, including annual Adult Physicals, Well-Women Visits, Mammograms, Colorectal Cancer Screening and other preventive care services Well-Child Care (Age/Frequency schedules apply, includes coverage for immunizations) $4,000 / $8,000 $4,500 / $9,000 $10,000 / $10,000 $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Vision Screening Services (1 time every 24 months) $0, deductible waived $0, deductible waived $0, deductible waived Prescription Lens Allowance $125 every 24 months $125 every 24 months $125 every 24 months Physician Services Primary Care Physician Office visit $30, deductible waived $30, deductible waived $30, deductible waived Specialist Office Visit $60, deductible waived $60, deductible waived 100%, deductible applies Mental Health Outpatient (25 visits per year) $60, deductible waived $60, deductible waived 100%, deductible applies Inpatient Services Hospital Inpatient 80%, deductible applies 70%, deductible applies 100%, deductible applies Mental Health Inpatient (30 days per year) 80%, deductible applies 70%, deductible applies 100%, deductible applies Outpatient/Other Services Diagnostic Lab $0, deductible waived $0, deductible waived 100%, deductible applies Diagnostic X-ray $60, deductible waived $75, deductible waived 100%, deductible applies Diagnostic Complex Imaging (CAT, MRI, MRA/MRS and PET scans) 80%, deductible applies 70%, deductible applies 100%, deductible applies Outpatient Surgery 80%, deductible applies 70%, deductible applies 100%, deductible applies Emergency Room (Copay waived if admitted) $300, deductible waived $300, deductible waived 100%, deductible applies Urgent Care $75, deductible waived $100, deductible waived 100%, deductible applies Ambulance (Emergency transport) 80%, deductible applies 70%, deductible applies 100%, deductible applies Durable Medical Equipment ($3,000 maximum per year) Outpatient Rehabilitative Therapy (30 visits per year, combined with Chiropractic Services) Chiropractic Services (30 visits per year, combined with Outpatient Rehabilitative Therapy) PHARMACY Retail Pharmacy Copay Mail-Order Drugs (MOD) (Available at 2X copay for a 31-90 day supply) 80%, deductible applies 70%, deductible applies 100%, deductible applies 80%, deductible applies 70%, deductible applies 100%, deductible applies 80%, deductible applies 70%, deductible applies 100%, deductible applies $15 / $45 / $65 $15 / $45 / $65 $15 / $45 / $65 Self-Injectable Drugs 30% 30% 30% ($30 minimum, $120 maximum copay) OUT-OF-NETWORK (oon) SERVICES Coinsurance 50% 50% 70% Annual Deductible: Individual/Family $3,500 / $7,000 $4,000 / $8,000 $10,000 / $10,000 Annual Out-of-Pocket (OOP): Individual/Family (Deductible applies to OOP) $7,000 / $14,000 $8,000 / $16,000 $15,000 / $30,000 Emergency Room Paid as In-Network Benefits Paid as In-Network Benefits Paid as In-Network Benefits Ambulance (Emergency transport) All Other Services 50%, deductible applies 50%, deductible applies 70%, deductible applies Retail Pharmacy 70% after copay 70% after copay 70% after copay See page 11 for footnotes. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 9
T E N N E S S E E p l a n G U I D E T E N N E S S E E ( 2-5 0 E m p l o y E E S ) PLAN OPTIONS TN MCOA 10-21 (HSA Compatible) TN MCOA 10-22 (HSA Compatible) Lifetime Maximum Unlimited Unlimited Unlimited IN-NETWORK SERVICES Coinsurance 70% 100% 80% TN Ind 10-40 Annual Deductible: Individual/Family $3,000 / $6,000 $5,950 / $11,900 $1,500 / $3,000 Type of Deductible NonEmbedded NonEmbedded 2X Annual Out-of-Pocket (OOP): Individual/Family (Deductible applies to OOP) Wellness On Us SM $5,950 / $11,900 $5,950 / $11,900 $5,000 / $10,000 Preventive Care, including annual Adult Physicals, Well-Women Visits, Mammograms, Colorectal Cancer Screening and other preventive care services Well-Child Care (Age/Frequency schedules apply, includes coverage for immunizations) $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived Vision Screening Services (1 time every 24 months) $0, deductible waived $0, deductible waived $0, deductible waived Prescription Lens Allowance $125 every 24 months $125 every 24 months $125 every 24 months Physician Services Primary Care Physician Office visit 70%, deductible applies 100%, deductible applies 80%, deductible applies Specialist Office Visit 70%, deductible applies 100%, deductible applies 80%, deductible applies Mental Health Outpatient (25 visits per year) 70%, deductible applies 100%, deductible applies 80%, deductible applies Inpatient Services Hospital Inpatient 70%, deductible applies 100%, deductible applies 80%, deductible applies Mental Health Inpatient (30 days per year) 70%, deductible applies 100%, deductible applies 80%, deductible applies Outpatient/Other Services Diagnostic Lab 70%, deductible applies 100%, deductible applies 80%, deductible applies Diagnostic X-ray 70%, deductible applies 100%, deductible applies 80%, deductible applies Diagnostic Complex Imaging (CAT, MRI, MRA/MRS and PET scans) 70%, deductible applies 100%, deductible applies 80%, deductible applies Outpatient Surgery 70%, deductible applies 100%, deductible applies 80%, deductible applies Emergency Room (Copay waived if admitted) 70%, deductible applies 100%, deductible applies 80%, deductible applies Urgent Care 70%, deductible applies 100%, deductible applies 80%, deductible applies Ambulance (Emergency transport) 70%, deductible applies 100%, deductible applies 80%, deductible applies Durable Medical Equipment ($3,000 maximum per year) Outpatient Rehabilitative Therapy (30 visits per year, combined with Chiropractic Services) Chiropractic Services (30 visits per year, combined with Outpatient Rehabilitative Therapy) 70%, deductible applies 100%, deductible applies 80%, deductible applies 70%, deductible applies 100%, deductible applies 80%, deductible applies 70%, deductible applies 100%, deductible applies 80%, deductible applies PHARMACY Retail Pharmacy Copay Mail-Order Drugs (MOD) (Available at 2X copay for a 31-90 day supply) $15 / $45 / $65 Discount Card Available $15 / $45 / $65 Self-Injectable Drugs ($30 minimum, $120 maximum copay) OUT-OF-NETWORK (oon) SERVICES 30% 70% after copay Coinsurance 50% 70% Same as In-Network Annual Deductible: Individual/Family $4,000 / $8,000 $7,000 / $14,000 Benefits Annual Out-of-Pocket (OOP): Individual/Family (Deductible applies to OOP) $8,000 / $16,000 $10,000 / $20,000 Emergency Room Paid as In-Network Benefits Paid as In-Network Benefits Ambulance (Emergency transport) All Other Services 50%, deductible applies 70%, deductible applies Retail Pharmacy 70% after copay Not Covered See page 11 for footnotes. 10
footnotes The federal health care reform legislation known as the Patient Protection and Affordable Care Act was signed into law on March 23, 2010. 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 benefits program complies with the new reform legislation. This is a partial description of plans and benefits available; for more information, refer to the specific plan design summary. The dollar amount copayments indicate what the member is required to pay and the percentage copayments indicate what Aetna is required to pay. NOTE: Some benefits are subject to limitations or visit maximums. Members or Providers may be required to precertify or obtain prior approval for certain services such as non-emergency hospital care. For a summary list of Limitations and Exlusions, refer to pages 34-35. Mandatory Generic (MG) with Dispensed as Written Override (DAW) Member pays the applicable coinsurance only, if the physician requires brand. If the member requests brand when a generic is available, the member pays the applicable coinsurance plus the difference between the generic price and the brand Plan includes contraceptive drugs and devices obtainable from a pharmacy and diabetic supplies. Precertification included. * Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered expenses accumulate toward the preferred and nonpreferred Deductible separately. Once the family deductible is met by any combination of family members, all family members will be considered as having met their Deductible for the remainder of the calendar year. 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 or hospital. 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 outof-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. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 11
T E N N E S S E E p l a n g u i d e Aetna Avenue dental Overview Aetna dental plans 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 (DMI) 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. Once at the dentist, these at-risk members will receive enhanced dental benefits including an extra cleaning and full coverage for certain periodontal services. 1 The professional entity, Academy of General Dentistry, 2007. *DMI may not be available in all states. 12
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. 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. **Discounts for non-covered services may not be available in all states. Discounts are not insurance. Aetna Dental Preventive Care SM Plan The Preventive Care plan is a lowercost 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 tooth whitening.** M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 13
T E N N E S S E E p l a n G U I D E A e t n a 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 (Dental Standalone) to Groups with 3 50 Eligible Employees Option 1 Option 2 Option 3 Low Passive PPO 100/80/50 Medium Passive PPO 100/80/50 High Passive PPO 10/80/50 Office Visit Copay N/A N/A N/A Annual Deductible per Member $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum (Does not apply to Diagnostic & Preventive services) Annual Maximum Benefit $1,000 $1,500 $2,000 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% 80% 80% Resin filling 2 surfaces, anterior 80% 80% 80% Oral Surgery Extraction exposed root or erupted tooth 80% 80% 80% Extraction of impacted tooth soft tissue 80% 80% 80% *Major Services Complete upper denture 50% 50% 50% Partial upper denture (resin base) 50% 50% 50% Crown Porcelain with noble metal 50% 50% 50% Pontic Porcelain with noble metal 50% 50% 50% Inlay Metallic (3 or more surfaces) 50% 50% 50% Oral Surgery Removal of impacted tooth partially bony 50% 80% 80% Endodontic Services Bicuspid root canal therapy 50% 80% 80% Molar root canal therapy 50% 80% 80% Periodontic Services Scaling & root planing per quadrant 50% 80% 80% Osseous surgery per quadrant 50% 80% 80% *Orthodontic Services Not covered 50% 50% Orthodontic Lifetime Maximum 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. Access to negotiated discounts; On the PPO plans in Plan Options 1-5, 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. All Endodontic, Periodontic and Oral Surgical services are covered as Basic Services on the PPO in Plan Options 2, 3 & 4. Out-of-Network plan payments are limited by geographic area on Plan Options 1-5 to the prevailing fees at the 80th percentile. Orthodontic coverage is available only to groups with 10 or more eligibles and to dependent children only. PPO plans: Discounts for non-covered services may not be available in all states. Above list of covered services is representative.full list with limitations as determined by Aetna appears in the plan booklet/certificate. 14
A E T N A 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 (Dental Standalone) to Groups with 3 50 Eligible Employees High Active PPO In Network 100/90/60 Option 4 Option 5 High Active PPO Out of Network 80/60/50 Passive PPO Aetna Dental Preventive Care Office Visit Copay N/A N/A N/A Annual Deductible per Member $50; 3X Family Maximum $50; 3X Family Maximum None (Does not apply to Diagnostic & Preventive services) Annual Maximum Benefit $2,000 $1,500 None Diagnostic Services Oral Exams Periodic oral exam 100% 80% 100% Comprehensive oral exam 100% 80% 100% Problem-focused oral exam 100% 80% 100% X-rays Bitewing single film 100% 80% 100% Complete series 100% 80% 100% Preventive Services Adult Cleaning 100% 80% 100% Child Cleaning 100% 80% 100% Sealants per tooth 100% 80% 100% Fluoride application with cleaning 100% 80% 100% Space maintainers 100% 80% 100% Basic Services Amalgam filling 2 surfaces 90% 60% Not Covered Resin filling 2 surfaces, anterior 90% 60% Not Covered Oral Surgery Extraction exposed root or erupted tooth 90% 60% Not Covered Extraction of impacted tooth soft tissue 90% 60% Not Covered *Major Services Complete upper denture 60% 50% Not Covered Partial upper denture (resin base) 60% 50% Not Covered Crown Porcelain with noble metal 60% 50% Not Covered Pontic Porcelain with noble metal 60% 50% Not Covered Inlay Metallic (3 or more surfaces) 60% 50% Not Covered Oral Surgery Removal of impacted tooth partially bony 90% 60% Not Covered Endodontic Services Bicuspid root canal therapy 90% 60% Not Covered Molar root canal therapy 90% 60% Not Covered Periodontic Services Scaling & root planing per quadrant 90% 60% Not Covered Osseous surgery per quadrant 90% 60% Not Covered *Orthodontic Services 50% 50% Not Covered Orthodontic Lifetime Maximum $1,000 $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. Access to negotiated discounts; On the PPO plans in Plan Options 1-5, 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. All Endodontic, Periodontic and Oral Surgical services are covered as Basic Services on the PPO in Plan Options 2, 3 & 4. Out-of-Network plan payments are limited by geographic area on Plan Options 1-5 to the prevailing fees at the 80th percentile. Orthodontic coverage is available only to groups with 10 or more eligibles and to dependent children only. PPO plans: Discounts for non-covered services may not be available in all states. Above list of covered services is representative.full list with limitations as determined by Aetna appears in the plan booklet/certificate. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 15
T E N N E S S E E p l a n G U I D E A e t n a 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 (Dental Standalone) to Groups with 3 50 Eligible Employees Voluntary Option 1 Voluntary Option 2 Voluntary Option 3 Voluntary Option 4 Low Passive PPO 100/80/50 Medium Passive PPO100/80/50 High Passive PPO 10/80/50 Passive PPO Aetna Dental Preventive Care Office Visit Copay N/A N/A N/A N/A Annual Deductible per Member $75; 3X Family Maximum $75; 3X Family Maximum $75; 3X Family Maximum None (Does not apply to Diagnostic & Preventive services) Annual Maximum Benefit $1,000 $1,500 $2,000 None Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% 100% Comprehensive oral exam 100% 100% 100% 100% Problem-focused oral exam 100% 100% 100% 100% X-rays Bitewing single film 100% 100% 100% 100% Complete series 100% 100% 100% 100% Preventive Services Adult Cleaning 100% 100% 100% 100% Child Cleaning 100% 100% 100% 100% Sealants per tooth 100% 100% 100% 100% Fluoride application with cleaning 100% 100% 100% 100% Space maintainers 100% 100% 100% 100% Basic Services Amalgam filling 2 surfaces 80% 80% 80% Not Covered Resin filling 2 surfaces, anterior 80% 80% 80% Not Covered Oral Surgery Extraction exposed root or erupted tooth 80% 80% 80% Not Covered Extraction of impacted tooth soft tissue 80% 80% 80% Not Covered *Major Services Complete upper denture 50% 50% 50% Not Covered Partial upper denture (resin base) 50% 50% 50% Not Covered Crown Porcelain with noble metal 50% 50% 50% Not Covered Pontic Porcelain with noble metal 50% 50% 50% Not Covered Inlay Metallic (3 or more surfaces) 50% 50% 50% Not Covered Oral Surgery Removal of impacted tooth partially bony 50% 80% 80% Not Covered Endodontic Services Bicuspid root canal therapy 50% 80% 80% Not Covered Molar root canal therapy 50% 80% 80% Not Covered Periodontic Services Scaling & root planing per quadrant 50% 80% 80% Not Covered Osseous surgery per quadrant 50% 80% 80% Not Covered *Orthodontic Services Not covered 50% 50% Not Covered Orthodontic Lifetime Maximum Does not apply $1,000 $1,000 Not Covered *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 the PPO plans in Plan Options 1-4, 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. All Endodontic and Periodontic services are covered as Basic Services on the PPO in Plan Options 2 & 3. Out-of-Network plan payments are limited by geographic area on Plan Options 1-4 to the prevailing fees at the 80th percentile. Orthodontic coverage is available only to groups with 10 or more eligibles and to dependent children only. PPO plans: Discounts for non-covered services may not be available in all states. Above list of covered services is representative. Full list with limitations as determined by Aetna appears in the plan booklet/certificate. 16
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 Plan Low Option No Ortho PPO Max Plan 100/80/50 Low Option Ortho PPO Max Plan 100/80/50 Medium Option No Ortho PPO Max Plan 100/80/50 Medium Option Ortho PPO Max Plan 100/80/50 Office Visit Copay N/A N/A N/A N/A Annual Deductible per Member $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum (Does not apply to Diagnostic & Preventive services) Annual Maximum Benefit $1,000 $1,000 $1,500 $1,500 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% 100% Comprehensive oral exam 100% 100% 100% 100% Problem-focused oral exam 100% 100% 100% 100% X-rays Bitewing single film 100% 100% 100% 100% Complete series 100% 100% 100% 100% Preventive Services Adult Cleaning 100% 100% 100% 100% Child Cleaning 100% 100% 100% 100% Sealants per tooth 100% 100% 100% 100% Fluoride application with cleaning 100% 100% 100% 100% Space maintainers 100% 100% 100% 100% Basic Services Amalgam filling 2 surfaces 80% 80% 80% 80% Resin filling 2 surfaces, anterior 80% 80% 80% 80% Oral Surgery Extraction exposed root or erupted tooth 80% 80% 80% 80% Extraction of impacted tooth soft tissue 80% 80% 80% 80% *Major Services Complete upper denture 50% 50% 50% 50% Partial upper denture (resin base) 50% 50% 50% 50% Crown Porcelain with noble metal 50% 50% 50% 50% Pontic Porcelain with noble metal 50% 50% 50% 50% Inlay Metallic (3 or more surfaces) 50% 50% 50% 50% Oral Surgery Removal of impacted tooth partially bony 50% 50% 50% 50% Endodontic Services Bicuspid root canal therapy 50% 50% 50% 50% Molar root canal therapy 50% 50% 50% 50% Periodontic Services Scaling & root planing per quadrant 50% 50% 50% 50% Osseous surgery per quadrant 50% 50% 50% 50% *Orthodontic Services Not covered 50% Not covered 50% Orthodontic Lifetime Maximum Does not apply $1,000 Does not apply $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. Above list of covered services is representative.full list with limitations as determined by Aetna appears on the plan booklet/certificate. 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. PPO plans: Discounts for non-covered services may not be available in all states. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 17
T E N N E S S E E 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 Plan PPO Max Plan 100/80/50 High Option No Ortho PPO Max Plan 100/80/50 Office Visit Copay N/A N/A Annual Deductible per Member $50; 3X Family Maximum $50; 3X Family Maximum (Does not apply to Diagnostic & Preventive services) Annual Maximum Benefit $2,000 $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% 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 Not covered 50% Orthodontic Lifetime Maximum Does not apply $1,000 High Option Ortho *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. Above list of covered services is representative.full list with limitations as determined by Aetna appears on the plan booklet/certificate. 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. PPO plans: Discounts for non-covered services may not be available in all states. 18
O U T- O F - S TAT E P P O V O L U N TA RY S M A L L G R O U P D E N TA L P L A N S Dental Plan PPO Max Plan 100/80/50 Option 1 No Ortho PPO Max Plan 100/80/50 Office Visit Copay N/A N/A Annual Deductible per Member $75; 3X Family Maximum $75; 3X Family Maximum (Does not apply to Diagnostic & Preventive services) Annual Maximum Benefit $1,000 $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 Not covered 50% Orthodontic Lifetime Maximum Does not apply $1,000 Option 1 Ortho *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. Above list of covered services is representative.full list with limitations as determined by Aetna appears on the plan booklet/certificate. 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. PPO plans: Discounts for non-covered services may not be available in all states. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 19