AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

A “health factor” means any of the following:
• Health status;
• A medical condition (whether physical or mental condition);
• Claims experience;
• Receipt of health care;
• Medical history;
• Evidence of insurability (including conditions arising out of acts of domestic violence and participation
in certain recreational activities, including high-risk activities);
• Disability; and
• Genetic information.
“Rules for eligibility” include, but are not limited to, rules relating to:
• Enrollment;
• The effective date of coverage;
• Waiting (or affiliation) periods;
• Late and special enrollment;
• Eligibility for benefit packages (including rules for individuals to change their selection among benefit
packages);
• Benefits (including rules related to covered benefits, benefit restrictions, and cost-sharing
mechanisms such as Coinsurance, Copayments and Deductibles);
• Continued eligibility; and
• Terminating coverage of any individual under a Plan.
NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT OF 1996
The Plan may not, under Federal law, restrict benefits for any Hospital length of stay in connection with
childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than
96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or
newborn’s attending Provider, after consulting with the mother, from discharging the mother or her
newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under
Federal law, require that a Provider obtain authorization from the plan or the insurance issuer for
prescribing a length of stay not in excess of 48 hours (or 96 hours).
WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998
As required by the Women’s Health and Cancer Rights Act of 1998 (the “WHCRA”), since the Plan
provides medical and surgical benefits for mastectomies, the Plan also provides coverage for
reconstructive surgery and related services related that may follow mastectomies. In compliance with the
WHCRA, the Plan covers:
● Reconstruction of the breast on which the mastectomy was performed;
● Reconstruction and Surgery of the other breast to achieve symmetry between the breasts; and
● Prostheses and treatment of physical complications of all stages of the mastectomy (including
lymphedema).
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