AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

More documents

Recommendations

Info

o Replacement of purchased equipment if Aetna is shown that it is needed due to a change in the Covered Individual’s physical condition; or it is likely to cost less to purchase a replacement than to repair existing equipment or to rent like equipment • Professional ambulance service to transport a person from the place where he or she is Injured or stricken by Illness to the first Hospital where treatment is given • Artificial limbs and eyes Covered Expenses do not included are such things as: • Eyeglasses; • Vision aids; • Hearing aids; • Communication aids 64
COMPLEX IMAGING SERVICES Covered Expenses include charges for Complex Imaging Services received by a Covered Individual on an Outpatient basis when performed in: 1) A Physician's office 2) A Hospital Outpatient department or emergency room 3) A Hospital confinement 4) A licensed radiological facility Complex Imaging Services include: 1) C.A.T. Scans; 2) Magnetic Resonance Imaging (MRIs); 3) Positron Emission Tomography (PET Scans); and 4) any other Outpatient diagnostic imaging service costing over $500. Deductibles, Copayments and other cost sharing features; maximum benefit amounts; and exclusions apply NATIONAL MEDICAL EXCELLENCE PROGRAM ® (NME) The NME Program coordinates all solid organ and bone marrow transplants and other specialized care that cannot be provided within an NME Patient's local geographic area. When care is directed to a facility ("Medical Facility") more than 100 miles from the person's home, this Plan will pay a benefit for Travel and Lodging Expenses, but only to the extent described in the <strong>Benefits</strong> Summary. See the <strong>Benefits</strong> Summary for the Plan Lodging and Travel Expenses Maximums. TRAVEL EXPENSES These are expenses incurred by an NME Patient for transportation between his or her home and the Medical Facility to receive services in connection with a procedure or treatment. Also included are expenses incurred by a Companion for transportation when traveling to and from an NME Patient’s home and the Medical Facility to receive such services. LODGING EXPENSES These are expenses incurred by an NME Patient for lodging away from home while traveling between his or her home and the Medical Facility to receive services in connection with a procedure or treatment. The benefit payable for these expenses will not exceed the Lodging Expenses Maximum per person per night. Also included are expenses incurred by a Companion for lodging away from home: • While traveling with an NME Patient between the NME Patient’s home and the Medical Facility to receive services in connection with any listed procedure or treatment; or • When the Companion’s presence is required to enable an NME Patient to receive such services from the Medical Facility on an Inpatient or Outpatient basis. The benefit payable for these expenses will not exceed the Lodging Expenses Maximum per person per night. For the purpose of determining NME Travel Expenses or Lodging Expenses, a Hospital or other temporary residence from which an NME Patient travels in order to begin a period of treatment at the Medical Facility, or 65
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 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: • Services for weight loss render
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
show all

AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

Create successful ePaper yourself

Delete template?

Save as template?