Aetna Life Insurance Company Hartford, Connecticut 06156

Transcription

1 Aetna Life Insurance Company Hartford, Connecticut Extraterritorial Certificate Rider (GR-9N-CR1) Policyholder: The TLC Companies Group Policy No.: GP Rider: West Virginia ET Medical Issue Date: February 27, 2009 Effective Date: January 1, 2009 This certificate rider forms a part of the booklet certificate issued to you by Aetna describing the benefits provided under the policy specified above. This extraterritorial certificate-rider takes the place of any other medical extraterritorial certificate-rider issued to you on a prior date. Note: The provisions identified herein are specifically applicable ONLY for: Benefit plans which have been made available to you and/or your dependents by your Employer; Benefit plans for which you and/or your dependents are eligible; Benefit plans which you have elected for you and /or your dependents; The benefits in this rider are specific to residents of West Virginia. These benefits supersede any provision in your booklet certificate to the contrary unless the provisions in your certificate result in greater benefits. You are only entitled to these benefits, if you are a resident of West Virginia, and if the benefit value exceeds those benefits covered under the group policy and booklet certificate. Coverage for Dependent Children To be eligible, a dependent child must be: Unmarried; and Under 25 years of age. Routine Cancer Screenings Covered expenses include charges incurred for routine cancer screening as follows: 1 mammogram every 12 months for covered females age 35 and over; 1 Pap smear every 12 months; 1 gynecological exam every 12 months; 1 digital rectal exam and 1 prostate specific antigen (PSA) test every 12 months for covered males age 40 and older. The following tests are covered expenses if you are age 50 and older, or less than 50 but symptomatic, when recommended by your physician: 1 Sigmoidoscopy every 5 years for persons at average risk; or 1 Double contrast barium enema (DCBE) every 5 years for persons at average risk); or 1 Colonoscopy every 10 years for persons at average risk for colorectal cancer. 1 fecal occult blood test every 12 months The above age and frequency limits do not apply to a person at high risk for the type of cancer screened. 1

2 Diabetic Equipment, Supplies and Education Covered expenses include charges for the following services, supplies, equipment and training for the treatment of insulin- and non-insulin-dependent diabetes and gestational diabetes. Supplies: Include but are not limited to: Blood glucose monitors; Monitor supplies; Insulin; Injection aids; Syringes; Insulin infusion devices; Pharmacological agents for controlling blood sugar; Orthotics. Self-Management Education on the proper self-management and treatment of diabetes, including information on proper diets. This will be limited to (1) visits upon the diagnosis of diabetes; (2) visits when a physician identifies or diagnoses a significant change in the person s symptoms or condition that requires changes in self-management; and (3) when new medications or therapeutic processes relating to the person s treatment or management of diabetes have been identified as necessary. Important Reminder There are limits for reeducation or refresher education. Refer to the Summary of Benefits for details on these limits. Contraception Services Covered expenses include charges for contraceptive services and supplies provided on an outpatient basis, including: Contraceptive drugs and contraceptive devices that by law need physician's prescription and that have been approved by the Federal Drug Administration; Related outpatient services such as: Consultations; Exams; Procedures; and Other medical services and supplies. Not covered are: Charges for services which are covered to any extent under any other part of the Plan or any other group plans sponsored by your employer; and Charges incurred for contraceptive services while confined as an inpatient. Charges incurred for duplicate, lost, stolen or damaged contraceptive drugs and devices. 2

3 Note: When your employer is a religious employer that: qualifies as a tax-exempt organization under 26 United States Code, Section 501 (c) (3); and requested an exclusion under the Plan for outpatient contraceptives and outpatient contraceptive services because such coverage conflicts with the employer s religious beliefs and practices; and either: is listed in the Official Catholic Directory published by P.J. Kennedy and Sons; or meets the definition of a religious employer as defined in 26 United States Code, Section 3121 (w) (3) (A). Then outpatient contraceptive drugs and devices and outpatient contraceptive services are covered under this Plan only if they are: used to treat a medical condition that is covered under this Plan; or are necessary to preserve the life or health of the covered person. You must submit proof, satisfactory to Aetna, that the incurred expenses meet one of the requirements, specified above, with the claim. Treatment of a (GR-9N WV) Covered expenses for the treatment of serious mental illness by behavioral health providers include those incurred: During a stay in a hospital or residential treatment facility; For partial confinement treatment; and For outpatient treatment. Benefits are payable in the same way as those for any other disease. Coverage under this benefit does not include treatment of a mental disorder. Treatment of Mental Disorders <11SECTION170> Covered expenses include charges made for the treatment of other mental disorders by behavioral health providers. In addition to meeting all other conditions for coverage, the treatment must meet the following criteria: There is a written treatment plan prescribed and supervised by a behavioral health provider; The plan includes follow-up treatment; and The plan is for a condition that can favorably be changed. Benefits are payable for charges incurred in a hospital, psychiatric hospital, residential treatment facility or behavioral health provider's office for the treatment of mental disorders as follows: Inpatient Treatment Covered expenses include charges for room and board at the semi-private room rate, and other services and supplies provided during your stay in a hospital, psychiatric hospital or residential treatment facility. Inpatient benefits are payable only if your condition requires services that are only available in an inpatient setting. Partial Confinement Treatment Covered expenses include charges made for partial confinement treatment provided in a facility or program for the intermediate short-term or medically-directed intensive treatment of a mental disorder. Such benefits are payable if your condition requires services that are only available in a partial confinement treatment setting. 3

4 Outpatient Treatment Covered expenses include charges for treatment received while not confined as a full-time inpatient in a hospital, psychiatric hospital or residential treatment facility. The plan covers partial hospitalization services (more than 4 hours, but less than 24 hours per day) provided in a facility or program for the intermediate short-term or medically-directed intensive treatment. The partial hospitalization will only be covered if you would need inpatient care if you were not admitted to this type of facility. Important Reminder: Inpatient care must be precertified by Aetna. Refer to the How the Plan Works section for more information about precertification. Partial Confinement Treatment '' A plan of medical, psychiatric, nursing, counseling, or therapeutic services to treat mental disorders or serious mental illnesses. The plan must meet these tests: It is carried out in a hospital; psychiatric hospital or residential treatment facility; on less than a full-time inpatient basis. It is in accord with accepted medical practice for the condition of the person. It does not require full-time confinement. It is supervised by a psychiatric physician who weekly reviews and evaluates its effect. Day care treatment and night care treatment are considered partial confinement treatment. Mental Disorder '' An illness commonly understood to be a mental disorder, whether or not it has a physiological basis, and for which treatment is generally provided by or under the direction of a behavioral health provider such as a psychiatric physician, a psychologist or a psychiatric social worker. A mental disorder is not a serious mental illness as defined herein. Serious Mental Disorder This means the following serious mental disorders as defined in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders": Bipolar disorder. depressive disorder. Anxiety disorder. Panic disorder. Anorexia and bulimia. Pervasive developmental disorder (Autism). Schizoaffective disorder. Schizophrenia. Treatment is generally provided by, or under the direction of, a behavioral health provider such as a psychiatric physician, a psychologist, or a psychiatric social worker. 4

5 In regards to your Traditional Choice Medical Plan: PLAN FEATURES Inpatient Treatment of and Non- (GR 9N-S WV) Non- same basis as any other same basis as any other Outpatient Treatment of and Non- Non- same basis as any other same basis as any other In regards to your Open Choice and Open Choice High Deductible Health Plans: PLAN FEATURES NETWORK OUT-OF-NETWORK OTHER HEALTH CARE Inpatient Treatment Of and Non- (GR-9N S WV) Non-Serious Mental Illness Outpatient Treatment Of and Non- Non-Serious Mental Illness 5

6 In regards to your Open Access Managed Choice High Deductible Health Plan and Open Access Managed Choice Plans: PLAN FEATURES NETWORK OUT-OF-NETWORK Inpatient Treatment Of and Non- (GR 9N-S WV) Non- expenses are paid on the expenses are paid on the expenses are paid on the expenses are paid on the Outpatient Treatment Of and Non- Non- expenses are paid on the expenses are paid on the expenses are paid on the expenses are paid on the Ronald A. Williams Chairman, Chief Executive Officer, and President Aetna Life Insurance Company (A Stock Company) 6