AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

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COBRA continuation coverage under another plan, you and/or your eligible Dependents must exhaust the COBRA coverage before you and/or your eligible Dependents may enroll in this Plan under a special enrollment period. If you timely enroll, coverage under the Plan for you and/or your eligible Dependents will be effective on the date the other coverage is terminated. If you do not timely enroll, enrollment for yourself and/or your new eligible Dependent(s) must wait until the next Annual Open Enrollment period, to be effective at the beginning of the next Plan Year (unless another event occurs which would allow you to enroll yourself and/or your new eligible Dependent(s) prior to such time). If you acquire a new eligible Dependent as a result of marriage, birth, adoption, or placement for adoption, you will be entitled to special enrollment in the Plan if you meet one of the following conditions: ● Non-Enrolled Associate: If you are an eligible Associate but have not enrolled in the Plan, you may enroll upon your marriage, or upon the birth, adoption, or placement for adoption of your child. ● Non-Enrolled Spouse: If you are an eligible Associate who is already enrolled in the Plan, you may enroll your spouse at the time of his or her marriage to you. You may also enroll your spouse if you acquire a child through birth, adoption, or placement for adoption. ● New Dependents of an Enrolled Associate: If you are an eligible Associate who is already enrolled in the Plan, you may enroll a child who becomes your eligible Dependent as a result of marriage, birth, adoption, or placement for adoption. ● New Dependents/Spouse of a Non-Enrolled Associate: If you are an eligible Associate but you are not enrolled in the Plan, you may enroll a spouse or child, as applicable, who becomes your eligible Dependent as a result of marriage, birth, adoption, or placement for adoption. However, you (the nonenrolled Associate) must also be eligible to enroll in the Plan, and actually enroll in the Plan at the same time. You must enroll yourself and/or your new eligible Dependent(s) no later than 30 days after the date of the event that entitles you and/or your eligible Dependent(s) to the special enrollment period. Coverage will become effective as of the date of the event. If you do not timely enroll, enrollment for yourself and/or your new eligible Dependent(s) must wait until the next Annual Open Enrollment period, to be effective at the beginning of the next Plan Year (unless another event occurs which would allow you to enroll yourself and/or your new eligible Dependent(s) prior to such time). In addition to the above, under the Children’s Health Insurance Program Reauthorization Act of 2009, you may enroll yourself and/or your eligible Dependent in the Plan if (1) you and/or your eligible Dependent lose Medicaid or Children’s Health Insurance Program (“CHIP”) coverage due to no longer being eligible for those benefits, or (2) you and/or your eligible Dependent become eligible for premium assistance in the Plan under a Medicaid program or CHIP. You must enroll in the Plan due to one of these reasons no later than 60 days after the date of the event that entitles you and/or your eligible Dependent to the special enrollment period. If you enroll within 60 days after the date of the event, coverage will become effective as of the date of the event. If you do not timely enroll, enrollment for you and/or your eligible Dependent must wait until the next Annual Open Enrollment period, to be effective at the beginning of the next Plan Year (unless another event occurs which would allow you to enroll yourself and/or your new eligible Dependent prior to such time). CHANGE IN STATUS The benefit choices you make are in effect for one entire Plan Year and generally may be changed only during the Annual Open Enrollment period. Elections you make during Annual Open Enrollment are effective beginning January 1 of the following Plan Year. The exception to this rule prohibiting election changes during a Plan Year is the occurrence of a special enrollment event described above or a qualified change in status event described in this section. Qualified change in status events include the following: 16
• Change in marital status, including marriage, divorce, legal separation, annulment or death of spouse • Change in number of Dependents, including birth, death, adoption, and placement for adoption • Change in employment status of the Associate, spouse or Dependent child that causes you, your spouse or Dependent child to either gain or lose eligibility for an employer’s benefit program, including: o Commencement or termination of employment, o Change in worksite that removes the affected individual from a benefit plan’s service provider area, o Commencement or return from leave of absence, or o Any employment status change that affects the eligibility of the individual to participate in a benefit program or plan of an employer, including a change from part-time to full-time employment or vice-versa, or a change from salaried to hourly pay, or, a strike or lockout. • Change in residence of the Associate, spouse or Dependent that removes the affected individual from the Plan’s service provider area (such a change entitles you to make a new Plan election selecting another coverage option, but generally does not permit you to opt out of coverage entirely unless no other relevant coverage is available). • Dependent meeting or ceasing to meet the Plan’s definition of Dependent, such as attainment of a specified age or a change in the Plan’s eligibility requirements. • Cost or Coverage - A significant change in the cost or coverage of a benefit plan offered to you, your spouse or other Dependent, including a new benefit option being added, a benefit option being eliminated or significantly curtailed, a coverage change made under a plan offered by the Employer or the employer of your spouse, former spouse or other Dependent, or a significant increase in the cost of a benefit (such qualified change in status permits you to make a new benefit selection, but does not allow you to revoke coverage entirely, unless no other similar coverage is available). • You, your spouse or other Dependent become covered or lose benefit coverage under Medicare or Medicaid, other than for pediatric vaccines. • A judgment, decree or order requiring Dependent coverage (e.g., QMCSO). • A special enrollment right you may be entitled to under the provisions of the Health Insurance Portability and Accountability Act of 1996, as amended (“HIPAA”). • You commence or return from an unpaid leave of absence as permitted and regulated by the Family Medical Leave Act (“FMLA”). • A change in coverage under another employer’s group health plan if the other group health plan permits participants to make an election change under the circumstances listed above or an election of coverage by your spouse, former spouse or Dependent during an open enrollment period under another employer’s group health plan that differs in time from the Annual Open Enrollment period. If you want to make an election change due the occurrence of a qualified change in status event, you must make the election change within 30 days after the date that the event occurs. Appropriate documentation is required. You may only make changes to benefit coverage under the Plan that are consistent with the qualified change in status event. For example, if the documentation you provide is for the birth of a child, you may increase your benefit coverage level to two person or family; however you cannot decrease the benefit coverage level or opt out of coverage. If you make an election change due to the occurrence of a change in status event within 30 days after the event occurs, the change will be effective as soon as administratively practicable but not earlier than the first pay period after a new election is made and returned to the Plan Administrator. Qualified change in status events shall only be effective as to contributions and benefits under the Plan on and after the 17
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 and 16: URGENT CONDITION This means a sudde
Page 17 and 18: CONTINUATION OF COVERAGE FOR ILL ST
Page 19: During Annual Open Enrollment, you
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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