AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

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• Seven exams in the first 12 months of life; • Three exams in the second 12 months of life; • Three exams in the third 12 months of life; and • One annual physical examination thereafter. For all exams given to your child age 18 and over, Covered Expenses will not include charges for more than one exam per calendar year. FOR YOU AND YOUR SPOUSE: For all exams given to you or your spouse, Covered Expenses will not include charges for more than: • One exam in per calendar year for a person under age 65; and • One exam in per calendar year for a person age 65 and over. Also included, as Covered Expenses are charges made by a Physician for one annual routine gynecological exam. Included, as part of the exam is a routine Pap Smear. LIMITATIONS TO PREVENTIVE PHYSICAL EXAM EXPENSES This section does not cover charges for: • Services which are covered to any extent under any other part of this Plan or any other group plan sponsored by your Employer; • Services which are for diagnosis or treatment of a suspected or identified Injury or Illness; • Exams given while the Covered Individual is confined in a Hospital or other place for medical care; • Services not given by a Physician or under his or her direction; • Medicines, drugs, appliances, equipment or supplies; • Psychiatric, psychological, personality or emotional testing or exams; • Exams in any way related to employment; • Premarital exams; • Vision, hearing or dental exams; • A Physician's office visit in connection with immunization or testing for tuberculosis; or • Services and supplies furnished by a Non-Preferred Care Provider. PREVENTIVE HEARING EXAM EXPENSES Covered Expenses include charges for an audiometric exam. The services must be performed by: • A Physician certified as an otolaryngologist or otologist; or • An audiologist who either: o Is legally qualified in audiology; or o Holds a certificate of Clinical Competence in Audiology from the American Speech and Hearing Association in the absence of any applicable licensing requirements; and o Who performs the exam at the written direction of a legally qualified otolaryngologist or otologist. Covered Expenses will only cover charges for one hearing exam in per calendar year. 54
Not included are charges for: • Any ear or hearing exam to diagnose or treat an Illness or Injury; • Drugs or medicines; • Any hearing care service or supply which is a Covered Expense in whole or in part under any other part of this Plan or under any other plan of group benefits provided through your Employer; • Any hearing care service or supply for which a benefit is provided under any workers' compensation law or any other law of like purpose, whether benefits are payable as to all or only part of the charges; • Any hearing care service or supply which does not meet professionally accepted standards; • Any service or supply received while the person is not a Covered Individual; • Any exams given while the Covered Individual is confined in a Hospital or other facility for medical care; • Any exam required by an employer as a condition of employment, or which an employer is required to provide under a labor agreement or is required by any law of a government, or • Any service or supply furnished by a Non-Preferred Care Provider. HOSPICE CARE EXPENSES Charges made for the following furnished to a Covered Individual for Hospice Care when given as a part of a Hospice Care program are included as Covered Medical Expenses. FACILITY EXPENSES The charges made in its own behalf by a: • Hospice Facility; • Hospital; or • Convalescent Facility. Which are for: INPATIENT CARE Room and Board and other services and supplies furnished to a Covered Individual while a full-time Inpatient for: pain control and other acute and chronic symptom management. • Not included is any charge for daily room and board in a private room over the Private Room Limit. OUTPATIENT CARE Services and supplies furnished to a Covered Individual while not confined as a full-time Inpatient. OTHER EXPENSES FOR OUTPATIENT CARE Charges made by a Hospice Care Agency for: • Part-time or intermittent nursing care by an R.N. or L.P.N. for up to eight hours in any one day. • Medical social services under the direction of a Physician. These include: o Assessment of the Covered Individual’s: � Social, emotional, and medical needs; and 55
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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 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: LIMITATIONS TO HOME CARE EXPENSES C
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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