AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

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HOW SERVICES ARE PAID THROUGH THE PLAN Both you and the Employer pay a portion of the total cost for your health care coverage. This is called “cost sharing.” The total cost of your health care coverage includes payroll contributions, Copayments, Coinsurance amounts, Deductibles, claim costs, and administrative fees. Here is an explanation of how your health care coverage is paid. 1) When you elect coverage under the Plan, you pay for your coverage through payroll contributions. The amount of your contributions is based on the level of coverage you choose. 2) When you receive health care services, you must first meet the annual Deductible before the Plan starts to pay its portion of the expenses. The amount of the Deductible is based on your coverage level. Keep in mind, there is a Deductible for Covered Expenses and a separate Deductible for covered Prescription Drug expenses. 3) Once you have met the annual Deductible, you will pay a Copayment or Coinsurance amount for your health care services. A Copayment is a fixed flat-dollar amount you pay. The Plan pays the remaining amount. When you pay Coinsurance, you pay a percentage of the expense and the Plan pays the remaining percentage. 4) You will continue to pay Copayment or Coinsurance amounts for covered services until you meet the Out-of-Pocket Maximum. The Out-of-Pocket Maximum is the most you will pay for covered expenses during a Plan Year. Once you meet the Out-of-Pocket Maximum (based on your coverage level) the Plan will pay the remaining expenses for that Plan Year. You should note, certain expenses do not count toward the Out-of-Pocket Maximum and are listed below. The following amounts not counted toward the Out-of-Pocket Maximum expense limit and, therefore, not eligible for 100 percent payment even if the Out-of-Pocket Maximum expense limit is met: • Copayments • Deductibles • Amounts over the usual, customary, and Reasonable Charges (UCR) • Applicable Penalties • Coinsurance or Copayments for Prescription Drugs • Office visit Copayments • Hospital Inpatient Copayments • Coinsurance for services related to Temporomandibular Joint Syndrome • Coinsurance for infertility drugs Expenses applied toward the non-Network Out-of-Pocket Maximum will be used to satisfy the Network Outof-Pocket Maximum, and expenses applied to the Network Out-of-Pocket Maximum will be applied to the non-Network Out-of-Pocket Maximum. 44
COVERED MEDICAL EXPENSES The Plan provides coverage for most Medically Necessary services, procedures and supplies. Most specific services that are not covered are listed in this Booklet. The Plan is designed to provide levels of benefits based on the choices you make. By choosing the services of a Trinity Health Facility or a Network provider, you will receive a higher level of payment. Detailed information about how benefits will be paid can be found in the Benefits Summary. HOW WILL YOU BENEFIT FROM CHOOSING A NETWORK PROVIDER? The Plan has contracted with certain physician and hospital providers to be the Plan's Network providers. The Plan, Aetna, the Employer, and the Plan Administrator do not provide any guarantee concerning the care provided by Network providers. Copies of the PPO provider directories can be obtained, at no charge, from the Human Resources / Organization and Talent Effectiveness http://mybenefits.trinityhealth.org/columbus/2008.shtml. You, together with your physician, are ultimately responsible for determining the appropriate treatment regardless of coverage by this Plan. WHAT HAPPENS IF YOU ARE NOT ABLE TO USE A NETWORK PROVIDER? When you or your covered Dependent(s) choose to receive covered services or supplies from a Network provider, the Plan will pay as described in the Benefits Summary. NOTE: If a Network physician or facility cannot perform a course of treatment or procedure, you must obtain an approved referral prior to receiving services by a Non-Network physician or facility. In order to complete this process, you must contact Aetna at 1-800-544-5108. Whenever possible, a referral to a Trinity Health approved physician or facility will be provided. When that is not possible, your doctor may provide a referral to a Non-Network physician or facility. Please remember that the referral must be obtained prior to receiving the services from a Non-Network physician or facility. Failure to obtain an approved referral prior to receiving services will result in no benefits being paid. Please refer to the Benefits Summary for further information. If you and your covered Dependents reside in an area where Network providers are not available, the Plan will pay benefits at the Network level when services have been referred in accordance with the above. If you or your covered Dependents need emergency treatment for an accidental bodily injury or a lifethreatening medical emergency and seek treatment (via car or ambulance) at the nearest facility that is not a Trinity Health facility or Network provider, the Plan will pay benefits at the Network level. If a covered service, supply, course of treatment or procedure cannot be performed by a Trinity Health facility or a Network provider; the Plan will pay benefits at the Network level (with approved referral). Any related laboratory tests, x-rays or follow-up visits by the same Non-Network provider will be paid at the Network level. It is your responsibility to investigate the availability of a needed provider. If you seek or are referred for services from a Non-Network provider and such specialty provider and/or covered service, supply, course of treatment or procedure can be performed by a Network provider, the Plan will pay benefits at the Non-Network level. Any related laboratory tests, x-rays or follow-up visits by the same Non-Network provider will be paid at the Non-Network level. It is your responsibility to investigate the availability of a needed provider. If you or your covered Dependents use a Trinity Health or a Network facility for inpatient/outpatient services/procedures, but the Trinity Health or a Network facility uses a Non-Network provider for anesthesia, the interpretation of laboratory tests and x-rays and other Medically Necessary services, the Plan will pay benefits at the Network level. 45
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 and 44: 4) Assisting in Plan’s Reimbursem
Page 45 and 46: EMPLOYEE RETIREMENT INCOME SECURITY
Page 47: IMPORTANT INFORMATION ABOUT THE PLA
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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