AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

• Checks Medical Necessity of the Hospital admission and length of stay against generally accepted
medical standards,
• Suggests alternative treatment settings, if appropriate, and
• Assist with discharge planning.
You will be notified by mail of the approved length of stay. Additional days may be assigned based on
Medical Necessity.
The final decision regarding treatment and Hospitalization is yours. Maximum allowable Plan benefits are
paid as long as these steps are followed prior to any Inpatient Hospitalization.
If you or a covered Dependent are admitted to a hospital for any reason without prior approval:
• Contact Aetna by telephone within two business days of the admission. You, a family member, or
your Physician may make the contact.
MENTAL DISORDERS AND/OR SUBSTANCE ABUSE
In addition, all Inpatient services (including partial Hospitalization), intensive Outpatient services, and
Outpatient psychiatric testing for Mental Disorders and/or substance abuse require pre-certification
through Aetna Behavioral Health. Please note that if pre-certification is not received for these services,
benefits will not be payable. For pre-certification coordination contact:
Aetna, Inc.
P.O. Box 981107
El Paso, TX 79998-1107
800-544-5108
Benefits available under this Plan for the treatment of Mental Disorders and/or substance abuse are
payable as described in Benefits Summary.
EXPLANATION OF SOME IMPORTANT PLAN PROVISIONS
INPATIENT FACILITY COPAY
This is the amount of Inpatient Facility Expenses you pay for each Hospital, each Convalescent Facility, or
each treatment facility confinement of a Covered Individual. The Inpatient Hospital Copay will only be applied
once to all Hospital confinements, regardless of cause, which are separated by less than 90 days.
CALENDAR YEAR DEDUCTIBLE
This is the amount of Covered Expenses you pay each calendar year before benefits are paid. There is a
Calendar Year Deductible that applies to each Covered Individual.
FAMILY DEDUCTIBLE LIMIT
If Covered Expenses incurred in a calendar year by you and your Dependents and applied against the
separate Calendar Year Deductibles equal the Family Deductible Limit, you and your Dependents will be
considered to have met the separate Calendar Year Deductibles for the rest of that calendar year.
HOSPITAL EMERGENCY ROOM COPAY
A separate Hospital Emergency Room Copay applies to each visit for emergency room care, by a Covered
Individual to a Hospital's emergency room, unless the Covered Individual is admitted to the Hospital as an
Inpatient immediately following a visit to a Hospital emergency room.
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