AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

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ELIGIBILITY ELIGIBLE ASSOCIATES You are eligible to participate in the Plan if you are a benefits-eligible Associate, as defined in your Employer’s policy that defines Associate classifications. Please contact your Employer for a copy of its policy that defines Associate classifications. ELIGIBLE DEPENDENTS Your spouse is eligible for coverage under the Plan provided he or she meets both of the following criteria: 1) The person is legally married to you under applicable State and Federal law and the IRS recognizes the person as your spouse for income tax purposes. A person who is your spouse as a result of a common law marriage is not eligible for coverage under the Plan. 2) The person is not otherwise covered under the Plan or any other group health plan offered by the Employer. Your children are eligible for coverage under the Plan through the end of the Plan Year in which they turn age 26, regardless of marital status, student status, residency, financial dependency or other requirements provided they meet both of the following criteria: 1) They are: • Your natural children; • Your legally adopted children or children placed with you for adoption; • Your stepchildren (i.e., the natural or legally adopted children of your legal spouse (as defined above)); or • Children for whom you or your legal spouse are the court-appointed legal guardian. 2) They are not otherwise covered under the Plan or any other group health plan offered by the Employer. In addition, the children listed above are eligible for coverage under the Plan after they turn age 26 if they meet all of the following criteria: 1) They are totally and permanently Disabled and become Disabled prior to their 26 th birthday. 2) They are unmarried. 3) They are not otherwise covered under the Plan or any other group health plan offered by the Employer. 4) They are continuously enrolled in a creditable plan prior to their 26 th birthday. 5) They either: a) Live in the same house as you for more than half of the year and do not provide more than half of their own support for the year; or b) Are not anyone’s “qualifying children” for the year (as defined in Internal Revenue Code Section 152(c)) and you provide over half of their support for the year. To view the complete eligibility rules and documentation requirements for you and your family members, visit http://mybenefits.trinity-health.org. 12
CONTINUATION OF COVERAGE FOR ILL STUDENTS: MICHELLE’S LAW Effective January 1, 2010, the Employee Retirement Income Security Act of 1974 (ERISA) includes Michelle’s Law. To the extent Michelle’s Law is still applicable after the enactment of the Patient Protection and Affordable Care Act (PPACA) and its implementing regulations, the Plan will not terminate your covered Dependent child’s coverage if he or she cannot maintain a full-time course load due to a Medically Necessary leave of absence from school (or a reduction in his or her school hours to part-time student status for a Medically Necessary reason). A Dependent child is defined as a student enrolled in post-secondary education before the Medically Necessary leave of absence. The child will continue to be a Dependent for one year after the first day of any verified Medically Necessary leave of absence or, if earlier, the date coverage would otherwise terminate under the Plan because the child does not satisfy the other eligibility requirements for Dependent coverage (e.g., because the child attains age 26). QUALIFIED MEDICAL CHILD SUPPORT ORDERS The Plan will also provide coverage as required by the terms of a Qualified Medical Child Support Order (“QMCSO”). This coverage applies even if you do not have legal custody of the child; the child is not dependent on you for support, and regardless of any enrollment restrictions that may otherwise exist for Dependent coverage. If the Plan Administrator receives a valid QMCSO and you do not enroll the Dependent child, the custodial parent or state agency may enroll the affected child. Additionally, the Employer may withhold from your paycheck any contributions required for such coverage. A QMCSO is a court order or court-approved settlement agreement that provides for health benefits for a child of a group health plan participant or enforces one of the mandatory provisions of state law regarding the provision of health insurance to minors in such cases. A QMCSO gives the child the same rights as an Associate to receive benefits under a group health plan. A QMCSO may be either a National Medical Child Support Notice issued by a state child support agency or an order or a judgment from a state court or administrative body directing the Employer to cover a child under the Plan. Federal law provides that a QMCSO must meet certain form and content requirements to be valid. The Plan Administrator follows certain procedures to determine if a child support notice is “qualified.” You may receive a copy of these procedures at no charge. If you have any questions, or would like a copy of the child support order qualification procedures, please contact the Plan Administrator. WHO’S NOT ELIGIBLE • Your common law spouse; • Your legal spouse and/or child(ren) if covered under the Plan or other group health plan offered by Trinity Health as an Associate or Dependent; • Any individual who begins active service in the armed forces of any country, unless coverage is continued as provided under the Uniformed Services Employment and Reemployment Rights Act of 1994 (“USERRA”); and • Any individual who does not meet the definition of a benefits-eligible Associate or an eligible Dependent as described in this Eligibility section of this SPD. If you are ineligible for coverage, your spouse and your other Dependents are not eligible for coverage. 13
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 and 12: A service or supply is not Medicall
Page 13 and 14: charge Aetna determines to be the p
Page 15: URGENT CONDITION This means a sudde
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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