AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

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STATE OF MICHIGAN DISCLOSURE REQUIREMENT The Plan is a self-funded plan. Covered Individuals in this Plan are not insured. In the event this Plan does not ultimately pay expenses that are eligible for payment under this Plan for any reason, the individuals covered by this Plan may be liable for those expenses. The Medical Claims Administrator, Aetna, merely processes claims and does not insure that any medical expenses of individuals covered by this Plan will be paid. Complete and proper claims for benefits made by Covered Individuals will be promptly processed. In the event of a delay in processing, the Covered Individual shall have no greater right or interest or other remedy against the Medical Claims Administrator than as otherwise afforded by law. 40
EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (ERISA) STATEMENT OF PARTICIPANT RIGHTS As a participant in the Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974, as amended (“ERISA”). ERISA provides that all Plan participants shall be entitled to: RECEIVE INFORMATION ABOUT YOUR PLAN AND BENEFITS • Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as worksites and union halls, all documents governing the Plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. • Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated Summary Plan Description. The Plan Administrator may make a Reasonable Charge for the copies. • Receive a summary of the Plan’s annual financial report. The Plan Administrator is required to furnish each participant with a copy of this summary annual report. CONTINUE GROUP HEALTH PLAN COVERAGE • Continue health care coverage for yourself, spouse or other Dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your Dependents may have to pay for such coverage. Review this Summary Plan Description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights. • Reduction or elimination of exclusionary periods of coverage for preexisting conditions under the Plan, if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from the Plan or health insurance issuer when you lose coverage under the Plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a preexisting condition exclusion for 12 months (18 months for Late Enrollees) after your enrollment date in your coverage. PRUDENT ACTION BY PLAN FIDUCIARIES In addition to creating rights for Plan participants ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Plan, called “fiduciaries” of the plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. ENFORCE YOUR RIGHTS If your claim for a welfare benefit is denied or ignored, in whole or in part, you have the right to know why this was done, to obtain documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest annual report from the Plan and do not receive them within 30 days, 41
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 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: 4) Assisting in Plan’s Reimbursem
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

AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

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