AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

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to which he or she travels after discharge at the end of a period of treatment, will be considered to be the NME Patient’s home. TRAVEL AND LODGING BENEFIT MAXIMUM For all Travel Expenses and Lodging Expenses incurred in connection with any one procedure or treatment type: • The total benefit payable will not exceed the Travel and Lodging Maximum per episode of care • Benefits will be payable only for such expenses incurred during a period which begins on the day a Covered Individual becomes an NME Patient and ends on the earlier of: o One year after the day the procedure is performed; or o The date the NME Patient ceases to receive any services from the facility in connection with the procedure. Benefits paid for Travel Expenses and Lodging Expenses do not count against any Covered Individual’s Maximum Benefit. LIMITATIONS Travel Expenses and Lodging Expenses do not include, and no benefits are payable for, any charges which are included as Covered Expenses under any other part of this Plan. Travel Expenses do not include expenses incurred by more than one Companion who is traveling with the NME Patient. Lodging Expenses do not include expenses incurred by more than one Companion per night. WEIGHT MANAGEMENT The Plan provides for services as described below. For plan coverage specifics please refer to the Benefits Summary. COVERED EXPENSES All expenses related to the treatment of Morbid Obesity that are otherwise payable under the Plan will be considered allowable expenses (e.g. Surgery, hospitalization, anesthesia, office visits for a Physician, lab testing, psychotherapy, etc. Services will be payable as described in each respective section). For purposes of determining these benefits, the Plan will base the determination of Morbid Obesity on the Covered Individual’s Body Mass Index (BMI) or overweight status. A BMI greater than 40, or more than 80 pounds overweight for a female or more than 100 pounds overweight for a male will be considered indicative of Morbid Obesity. A BMI greater than 35 but less than 40 will also be considered indicative of Morbid Obesity where the patient has one or more of the following co-morbid conditions; severe sleep apnea, Pickwickian syndrome, Congestive heart failure, cardiomyopathy, Insulin dependent diabetes or severe musculoskeletal dysfunction, that are either life threatening or which significantly impair a major life function (e.g., mobility, ability to work, ability to self care). Documentation of the medical treatment of the co-morbid conditions that demonstrates the Covered Individual meets these criteria must be provided. Additionally, the Plan will review Covered Individual’s history for optimal candidacy for any proposed surgical treatment according to current, generally accepted medical practices. For example, this review will consider whether the Covered Individual has been unable to lose weight through non-surgical, conventional measures and whether the Covered Individual’s ability to manage the surgical intervention and required post-operative care has been assessed through a psychological evaluation. The Plan will review if the Covered Individual has undergone a Physician supervised nutrition, exercise and weight loss program for a minimum of six months, within the 12 months immediately preceding the proposed 66
Surgery, during which the Covered Individual was found unable to meet the Physician’s weight loss goals. Unsuccessful weight loss attempts and lifestyle changes will require documentation by medical office progress notes and a letter from the attending Physician as to why non-invasive weight loss attempts are no longer a standard of care for the patient. If confirmation is obtained from the attending surgeon that the program the Covered Individual will be under includes a complete support team with required follow ups, etc. a psychological evaluation is not required. Other limitations include: 1) Appendectomies and cholecystectomies in conjunction with surgical treatment of Morbid Obesity will be considered incidental and not covered unless the Covered Individual has an existing condition that requires the additional surgical treatment. 2) Subsequent panniculectomy (Surgery to remove loose skin) resulting from weight loss will be covered only if it is Medically Necessary as a result a documented history of treatment by a Physician for related Illnesses for a minimum of six months where the treated condition is no longer controlled through any other means. 3) Bariatric Surgical intervention beyond one course of treatment per lifetime. NOTE: Please refer to the sections titled CONSULTATIONS, LABORATORY/PATHOLOGICAL TESTING, X-RAY AND X-RAY INTERPRETATION and OFFICE VISITS for information regarding coverage for consultations, laboratory/pathological tests, x-rays and office visits related to covered weight management procedures. NOT COVERED: Prescription drugs without prior authorization LIMITATIONS PREVENTIVE MAMMOGRAM Even though not incurred in connection with an Illness or Injury, Covered Expenses include charges incurred by a female age 35 or over for a routine mammogram as follows: • One baseline mammogram, for a person age 35 but less than 40. • One mammogram each calendar year, for a person age 40 or over. PREVENTIVE SCREENING FOR CANCER Even though not incurred in connection with an Illness or Injury, Covered Expenses include charges incurred for: • One digital rectal exam and a prostate specific antigen (PSA) test each calendar year, for a male age 40 or over; and • One colorectal cancer screening every 10 years, for persons age 50 or over, for routine screening for cancer. • Also covers one sigmoidoscopy each calendar year, for a person age 40 or over. MOUTH, JAWS AND TEETH Covered Expenses include the services rendered and supplies needed for treatment of or related to conditions of the following: • Teeth, mouth, jaws, jaw joints; or 67
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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
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COBRA Continuation coverage as requ
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• Scientific data such as control
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A service or supply is not Medicall
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charge Aetna determines to be the p
Page 15 and 16:
URGENT CONDITION This means a sudde
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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 and 68: • Services for weight loss render
Page 69: COMPLEX IMAGING SERVICES Covered Ex
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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