AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

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PLAN ADMINISTRATOR Trinity Health PLAN YEAR The Plan Year is the 12-month period beginning on January 1 and ending on the following December 31. You have the opportunity to change your medical coverage during the Annual Open Enrollment period before the new Plan Year begins. PREFERRED CARE This is a health care service or supply furnished by a person’s Primary Care Physician or any other Preferred Care Provider. Also furnished by a person’s Primary Care Physician prior to treatment and a Non-Preferred Urgent Care Provider when travel to a Preferred Urgent Care Provider for treatment is not feasible. Preferred Care is also care, which is recommended and approved by the BHCC. PREFERRED CARE PROVIDER This is a health care provider that has contracted to furnish services or supplies for a Negotiated Charge; but only if the provider is, with Aetna’s consent, including in the directory as a Preferred Care Provider for the service or supply involved; and the class of associates of which you are member. PRESCRIPTION DRUG Those drugs approved by the Food and Drug Administration of the United States which require a written prescription by a Physician or Dentist and which bear the legend, “Caution: Federal law prohibits dispensing without a prescription.” PRIMARY CARE PHYSICIAN This is the Preferred Care Provider who is selected by a person from the list of Primary Care Physicians in the directory, is responsible for the person’s on-going health care; and is shown on Aetna’s records as the person’s Primary Care Physicians. PROVIDER A person (such as a Physician) or a facility (such as a Hospital) that provides services or supplies related to medical care. • Trinity Health Facilities – Trinity Health’s facilities, its Ministry Organization’s Hospitals and satellite locations. • Network Providers – Hospitals, Physicians and other licensed facilities or Health Care Professionals who have contracted with Aetna to provide services to members enrolled in a PPO health care Plan. Network Providers have agreed to accept Aetna’s approved amount as payment in full for Covered Services. • Nonparticipating (Out-of-Network) Providers — Providers who are not part of the Aetna PPO provider Network. Out-of-Network Providers have not signed participation agreements with Aetna agreeing to accept the Aetna payment as payment in full. However, nonparticipating Providers may agree to accept the Aetna approved amount as payment in full on a per claim basis. However, because these Providers are not a part of the PPO Network, you must pay higher out-of-pocket costs. R.N. This means a registered nurse. REASONABLE CHARGE The Reasonable Charge for a service or supply is the lowest of the Provider’s usual charge for furnishing it; and the charge Aetna determines to be appropriate, based on factors such as the cost of providing the same or a similar service or supply and the manner in which charges for the service or supply are made; and the 8
charge Aetna determines to be the prevailing charge level made for it in the geographic area where it is furnished. In determining the Reasonable Charge for a service or supply that is unusual, not often provided in the area or provided by only a small number of Providers in the area. Aetna may take into account factors, such as the complexity, degree of skill needed, type of specialty of the Provider, range of services or supplies provided by a facility, and prevailing charge in other areas. In some circumstances, Aetna may have an agreement with a Provider (either directly, or indirectly through a third party), which sets the rate that Aetna will pay for a service or supply. In these instances, in spite of the methodology described above, the Reasonable Charge is the rate established in such agreement. RESIDENTIAL TREATMENT FACILITY – ALCOHOLISM AND DRUG ABUSE This is an institution that meets all of the following requirements: • On-site licensed Behavioral Health Provider 24 hours per day/seven days a week • Provides a comprehensive patient assessment (preferably before admission, but at least upon admission) • Is admitted by a Physician • Has access to necessary medical services 24 hours per day/seven days a week • If the member requires detoxification services, must have the availability of on-site medical treatment 24 hours per day/seven days a week, which must be actively supervised by an attending Physician • Provides living arrangements that foster community living and peer interaction that are consistent with developmental needs • Offers group therapy sessions with at least an RN or Masters-Level Health Professional • Has the ability to involve family/support systems in therapy (required for children and adolescents; encouraged for adults) • Provides access to at least weekly sessions with a Psychiatrist or psychologist for individual psychotherapy • Has peer oriented activities • Services are managed by a licensed Behavioral Health Provider who, while not needing to be individually contracted, needs to (1) meet the Aetna credentialing criteria as an individual practitioner, and (2) function under the direction/supervision of a licensed psychiatrist (Medical Director) • Has individual active treatment plan directed toward the alleviation of the impairment that caused the admission • Provides a level of skilled intervention consistent with patient risk • Meets any and all applicable licensing standards established by the jurisdiction in which it is located • Is not a Wilderness Treatment Program or any such related or similar program, school and/or education service • Ability to assess and recognize withdrawal complications that threaten life or bodily functions and to obtain needed services either on site or externally • 24-hours per day/seven days a week supervision by a Physician with evidence of close and frequent observation • On-site, licensed Behavioral Health Provider, medical or substance abuse professionals 24 hours per day/seven days a week 9
Page 1 and 2: AETNA PPO PLAN SUMMARY PLAN DESCRIP
Page 3 and 4: Women’s Health and Cancer Rights
Page 5 and 6: PURPOSE This document, along with o
Page 7 and 8: COBRA Continuation coverage as requ
Page 9 and 10: • Scientific data such as control
Page 11: A service or supply is not Medicall
Page 15 and 16: URGENT CONDITION This means a sudde
Page 17 and 18: CONTINUATION OF COVERAGE FOR ILL ST
Page 19 and 20: During Annual Open Enrollment, you
Page 21 and 22: • Change in marital status, inclu
Page 23 and 24: • The last day of the pay period
Page 25 and 26: • CHIP participant; or • Depend
Page 27 and 28: SPECIFIC INFORMATION ABOUT YOUR COB
Page 29 and 30: notified of the Social Security Adm
Page 31 and 32: USERRA CONTINUATION COVERAGE If you
Page 33 and 34: Privacy of Health Information HIPAA
Page 35 and 36: Coverage will be provided in a mann
Page 37 and 38: not submitted sufficient informatio
Page 39 and 40: The notice of Adverse Benefit Deter
Page 41 and 42: Determination concerns an admission
Page 43 and 44: 4) Assisting in Plan’s Reimbursem
Page 45 and 46: EMPLOYEE RETIREMENT INCOME SECURITY
Page 47 and 48: IMPORTANT INFORMATION ABOUT THE PLA
Page 49 and 50: COVERED MEDICAL EXPENSES The Plan p
Page 51 and 52: necessary for the diagnosis or trea
Page 53 and 54: URGENT CARE COPAY A separate Urgent
Page 55 and 56: OUTPATIENT SURGICAL EXPENSES Covere
Page 57 and 58: LIMITATIONS TO HOME CARE EXPENSES C
Page 59 and 60: Not included are charges for: • A
Page 61 and 62: Short-term rehabilitation is therap
Page 63 and 64:
• Platelet Proliferation Stimulan
Page 65 and 66:
Effective July 1, 2011 (or such lat
Page 67 and 68:
• Services for weight loss render
Page 69 and 70:
COMPLEX IMAGING SERVICES Covered Ex
Page 71 and 72:
Surgery, during which the Covered I
Page 73 and 74:
• For root canal therapy; • For
Page 75 and 76:
GENERAL EXCLUSIONS GENERAL EXCLUSIO
Page 77 and 78:
• Those for or in connection with
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AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

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