AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

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CONTENTS Purpose..................................................................................................................................... 1 Highlights ................................................................................................................................. 1 Terms You Should Know ........................................................................................................ 2 Eligibility ................................................................................................................................. 12 Eligible Associates ............................................................................................................. 12 Eligible Dependents ........................................................................................................... 12 Continuation of Coverage for Ill Students: Michelle’s Law ................................................. 13 Qualified Medical Child Support Orders............................................................................. 13 Who’s Not Eligible.............................................................................................................. 13 Participation ........................................................................................................................... 14 When Participation Begins................................................................................................. 14 Making Benefit Elections.................................................................................................... 15 Special Enrollment Periods................................................................................................ 15 Change in Status................................................................................................................ 16 Enrolling After You Waive Participation ............................................................................. 18 Leaves of Absence............................................................................................................. 18 Rehired Associates ............................................................................................................ 18 When Coverage Ends........................................................................................................ 18 Coordination of Benefits .......................................................................................................20 Coordinating With Another Employer’s Plan...................................................................... 20 Guidelines to Determine Which Plan is Primary and Secondary ....................................... 20 Coordination with Medicare................................................................................................ 21 Updating COB Information – Your Responsibility .............................................................. 22 Specific Information About Your COB................................................................................ 23 Filing COB Claims to Your Secondary Carrier ................................................................... 23 No-Fault Auto Coverage .................................................................................................... 23 Submitting Coordinated Claims.......................................................................................... 23 Continuation of Group Health Coverage ............................................................................ 24 Qualifying Events ............................................................................................................... 24 Election of Coverage.......................................................................................................... 25 Requirements for All Notices.............................................................................................. 25 Cost of Continuation of Coverage ...................................................................................... 26 Termination of Continuation of Coverage .......................................................................... 26 Trade Act of 1974............................................................................................................... 26 USERRA Continuation Coverage ...................................................................................... 27 If You Have Questions ....................................................................................................... 27 Keep the Plan Informed of Address Changes.................................................................... 27 Plan Administration Information .......................................................................................... 28 Employment Rights............................................................................................................ 28 No Warranty of Health Care Providers............................................................................... 28 Designation of Fiduciary Responsibility ............................................................................. 28 Health Insurance Portability and Accountability Act of 1996 (HIPAA)................................ 28 Newborns’ and Mothers’ Health Protection Act of 1996..................................................... 30
Women’s Health and Cancer Rights Act of 1998............................................................... 30 Plan Administrator Powers................................................................................................. 31 Filing a Claim for Benefits and Review Procedures ........................................................... 31 How to Submit a Claim for Benefits ................................................................................... 31 Reporting of Claims............................................................................................................32 Claims, Appeals and External Review ............................................................................... 32 Filing Health Claims Under the Plan ............................................................................ 32 Other Claims ................................................................................................................ 32 Health Claims: Standard Appeals ................................................................................ 33 Exhaustion of Internal Appeals Process ...................................................................... 33 Full and Fair Review of Claim Determinations and Appeals ........................................ 33 Health Claims: Voluntary Appeals...................................................................................... 34 External Review ........................................................................................................... 34 Request for External Review........................................................................................ 35 Preliminary Review ...................................................................................................... 35 Referral to ERO............................................................................................................ 36 Expedited External Review .......................................................................................... 36 Referral of Expedited Review to ERO.......................................................................... 37 Legal Action ....................................................................................................................... 37 Subrogation and Right of Reimbursement ......................................................................... 37 Amendment or Termination of the Plan ............................................................................. 39 State of Michigan Disclosure Requirement ........................................................................ 40 Employee Retirement Income Security Act of 1974 (ERISA) Statement of Participant Rights ........................................................................................ 41 Important Information About the Plan ................................................................................. 43 How Services Are Paid Through the Plan ........................................................................... 44 Covered Medical Expenses................................................................................................... 45 How Will You Benefit From Choosing a Network Provider? .............................................. 45 What Happens If You Are Not Able to Use a Network Provider?....................................... 45 What Is The Plan Deductible?............................................................................................ 46 What Is Your Out-of-Pocket Maximum Expense?.............................................................. 46 Health Management Services............................................................................................ 46 Case Management............................................................................................................. 47 Pre-Certification of Services............................................................................................... 47 Mental Disorders and/or Substance Abuse........................................................................ 48 Explanation of Some Important Plan Provisions ................................................................ 48 Genetic Testing/Screening and Counseling....................................................................... 49 Hospital Expenses ............................................................................................................. 50 Inpatient Hospital Expenses......................................................................................... 50 Outpatient Hospital Expenses...................................................................................... 50 Outpatient Surgical Expenses...................................................................................... 51 Outpatient Services and Supplies ................................................................................ 51 Convalescent Facility Expenses ........................................................................................ 51 Home Health Care Expenses............................................................................................. 52 Preventive Physical Exam Expenses................................................................................. 53
Page 1: AETNA PPO PLAN SUMMARY PLAN DESCRIP
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 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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