BENEFIT PLAN. What Your Plan Covers and How Benefits are Paid. MD Bronze PPO /80 HSA Emb

Transcription

1 BENEFIT PLAN MD Bronze PPO /80 HSA Emb What Your Plan Covers and How Benefits are Paid Aetna Life Insurance Company 151 Farmington Avenue Hartford, Connecticut Booklet-Certificate This Booklet-Certificate is part of the Group Insurance Policy between Aetna Life Insurance Company and the Policyholder MD Bronze PPO /80 HSA Emb MDP HIXGR-96792

2 Table of Contents Schedule of Benefits... Issued with Your Booklet Preface...1 Important Information Regarding Availability of Coverage... 2 Coverage for You and Your Dependents...2 Health Expense Coverage...2 Treatment Outcomes of Covered Services... 2 When Your Coverage Begins...3 Who Can Be Covered...3 Obtaining Coverage for Dependents... 3 How and When to Enroll...4 Initial Enrollment in the Plan... 4 Late Enrollment... 5 Annual Enrollment... 5 Special Enrollment Periods... 5 When Your Coverage Begins...8 Your Effective Date of Coverage... 8 Your Dependent s Effective Date of Coverage... 8 How Your Medical Plan Works...10 Common Terms...10 About Your PPO Comprehensive Medical Plan.10 Availability of Providers...11 How Your PPO Plan Works...11 Cost Sharing For Network Benefits...12 Cost Sharing for Out-of-Network Benefits...13 Understanding Precertification...15 Services and Supplies Which Require Precertification...16 Emergency and Urgent Care...17 In Case of a Medical Emergency...17 Coverage for Emergency Medical Conditions...17 In Case of an Urgent Condition...17 Coverage for an Urgent Condition...18 Non-Urgent Care...18 Follow-Up Care After Treatment of an Emergency or Urgent Medical Condition...18 Requirements For Coverage...19 What The Plan Covers...20 PPO Medical Plan...20 Preventive Care...20 Routine Physical Exams...21 Routine Cancer Screenings...23 Vision Care Services...26 Physician Services...27 Physician Visits...27 Surgery...27 Anesthetics...27 Alternatives to Physician Office Visits...27 Hospital Expenses Room and Board Other Hospital Services and Supplies Outpatient Hospital Expenses Coverage for Emergency Medical Conditions Coverage for Urgent Conditions Alternatives to Hospital Stays Outpatient Surgery and Physician Surgical Services.. 31 Home Health Care Skilled Nursing Facility Hospice Care Other Covered Health Care Expenses Acupuncture Ambulance Service Ground Ambulance Air or Water Ambulance Diagnostic and Preoperative Testing Diagnostic Complex Imaging Expenses Outpatient Diagnostic Lab Work Outpatient Diagnostic Radiological Services Outpatient Preoperative Testing Durable Medical and Surgical Equipment (DME) Prosthetic Devices Cardiac and Pulmonary Rehabilitation Benefits Short-Term Rehabilitation Therapy Services Specialized Care Reconstructive or Cosmetic Surgery and Supplies Reconstructive Breast Surgery Chemotherapy Radiation Therapy Benefits Diabetic Equipment, Supplies and Education Treatment of Infertility Transplant Services Oral and Maxillofacial Treatment (Mouth, Jaws and Teeth) Mental Illness, Emotional Disorders, and Drug and Alcohol Abuse Services Treatment of Morbid Obesity Medical Plan Exclusions Your Pharmacy Benefit How the Pharmacy Plan Works Getting Started: Common Terms Accessing Pharmacies and Benefits Accessing Network Pharmacies and Benefits Emergency Prescriptions Availability of Providers HIXGR-96792

3 Cost Sharing for Network Benefits...53 When You Use an Out-of-Network Pharmacy...53 Cost Sharing for Out-of-Network Benefits...53 Retail Pharmacy Benefits...54 Mail Order Pharmacy Benefits...54 Other Covered Expenses...55 Precertification...56 Pharmacy Benefit Limitations...57 Pharmacy Benefit Exclusions...57 When Coverage Ends...59 When Coverage Ends for Employees...59 When Coverage Ends for Dependents...59 Continuation of Coverage...60 Continuing Health Care Benefits...60 Handicapped Dependent Children...62 Extension of Benefits...62 Coverage for Health Benefits...62 COBRA Continuation of Coverage...63 Continuing Coverage through COBRA...63 Who Qualifies for COBRA...63 Disability May Increase Maximum Continuation to 29 Months...64 Determining Your Premium Payments for Continuation Coverage...64 When You Acquire a Dependent During a Continuation Period...65 When Your COBRA Continuation Coverage Ends..65 Coordination of Benefits - What Happens When There is More Than One Health Plan...66 When Coordination of Benefits Applies Getting Started - Important Terms Which Plan Pays First How Coordination of Benefits Work Right To Receive And Release Needed Information 69 Facility of Payment Right of Recovery When You Have Medicare Coverage Which Plan Pays First How Coordination With Medicare Works General Provisions Physical Examinations Legal Action Confidentiality Additional Provisions Assignments Misstatements Subrogation and Right of Reimbursement Workers Compensation Recovery of Overpayments Health Coverage Reporting of Claims Payment of Benefits Records of Expenses Contacting Aetna Glossary * *Defines the Terms Shown in Bold Type in the Text of This Document. HIXGR-96792

4 Preface Aetna Life Insurance Company (ALIC) is pleased to provide you with this Booklet-Certificate. Read this Booklet-Certificate carefully. The plan is underwritten by Aetna Life Insurance Company of Hartford, Connecticut (referred to as Aetna). This Booklet-Certificate is part of the Group Insurance Policy between Aetna Life Insurance Company and the Policyholder. The Group Insurance Policy determines the terms and conditions of coverage. Aetna agrees with the Policyholder to provide coverage in accordance with the conditions, rights, and privileges as set forth in this Booklet-Certificate. The Policyholder selects the products and benefit levels under the plan. A person covered under this plan and their covered dependents are subject to all the conditions and provisions of the Group Insurance Policy. The Booklet-Certificate describes the rights and obligations of you and Aetna, what the plan covers and how benefits are paid for that coverage. It is your responsibility to understand the terms and conditions in this Booklet-Certificate. Your Booklet-Certificate includes the Schedule of Benefits and any amendments or riders. This Booklet-Certificate is not a Medicare supplement certificate. It is not designed to fill the gaps of Medicare. If you are eligible for Medicare, review the Medicare supplement buyer s guide available from Aetna. If you become insured, this Booklet-Certificate becomes your Certificate of Coverage under the Group Insurance Policy, and it replaces and supersedes all certificates describing similar coverage that Aetna previously issued to you. Booklet-Certificate Base: MD Bronze PPO /80 HSA Emb Mark T. Bertolini Chairman, Chief Executive Officer and President Aetna Life Insurance Company (A Stock Company) HIXGR

5 Important Information Regarding Availability of Coverage No services are covered under this Booklet-Certificate in the absence of payment of current premiums subject to the Grace Period and the Premium section of the Group Insurance Policy. Unless specifically provided in any applicable termination or continuation of coverage provision described in this Booklet-Certificate or under the terms of the Group Insurance Policy, the plan does not pay benefits for a loss or claim for a health care, medical or dental care expense incurred before coverage starts under this plan. This plan will not pay any benefits for any claims, or expenses incurred after the date this plan terminates. This provision applies even if the loss, or expense, was incurred because of an accident, injury or illness that occurred, began or existed while coverage was in effect. These provisions are subject to the Extension of Benefits and Continuation of Coverage sections of the Group Insurance Policy and Booklet-Certificate. Benefits may be modified during the term of this plan as specifically provided under the terms of the Group Insurance Policy or upon renewal. If benefits are modified, the revised benefits (including any reduction in benefits or elimination of benefits) apply to any expenses incurred for services or supplies furnished on or after the effective date of the plan modification. There is no vested right to receive any benefits described in the Group Insurance Policy or in this Booklet- Certificate beyond the date of termination or renewal including if the service or supply is furnished on or after the effective date of the plan modification, but prior to your receipt of amended plan documents. Coverage for You and Your Dependents Health Expense Coverage Benefits are payable for covered health care expenses that are incurred by you or your covered dependents while coverage is in effect. An expense is incurred on the day you receive a health care service or supply. Refer to the What the Plan Covers section of the Booklet-Certificate for more information about your coverage. Treatment Outcomes of Covered Services Aetna is not a provider of health care services and therefore is not responsible for and does not guarantee any results or outcomes of the covered health care services and supplies you receive. Except for Aetna RX Home Delivery LLC, providers of health care services, including hospitals, institutions, facilities or agencies, are independent contractors and are neither agents nor employees of Aetna or its affiliates. HIXGR

6 When Your Coverage Begins Who is Eligible to be Covered How and When to Enroll When Your Coverage Begins Throughout this section you will find information on who is eligible to be covered under the plan, how to enroll and what to do when there is a change in your life that affects coverage. In this section, you means the employee. Who is Eligible to be Covered The: eligibility process; enrollment process; and your notification process to the Maryland Health Benefit Exchange (the Exchange ) of all changes affecting any covered person s eligibility under this Policy; are subject to any rules, regulations or other standards set forth by the Maryland Health Benefit Exchange and/or the Maryland Insurance Administration or the Federal Department of Health and Human Services (the Department).Employees To be covered by this plan, the following requirements must be met: You will need to be in an eligible class, as defined below; You will need to meet the eligibility date criteria described below; You will need to live or work in the State of Maryland; and If required, approved by the Maryland Health Benefit Exchange. Obtaining Coverage for Dependents Your dependents can be covered under your plan. You may enroll the following dependents: Your spouse; or Your domestic partner A domestic partner under this Policy is a person who certifies the following: He or she is recognized as a domestic partner in accordance with applicable state law and at least age 18; and He or she is not married, in a civil union partnership, or domestic partnership with anyone else; and He or she is not related to the other by blood or marriage within four degrees of consanguinity under civil law rule; and He or she can demonstrate interdependence with you through at least one of the following: Common ownership or lease of real property (joint deed, mortgage or lease agreement); Driver s license listing a common address; Utility bills listing both names; Proof of joint bank accounts or credit accounts; Proof of designation as the primary beneficiary for life insurance or retirement benefits, or primary beneficiary designation under your will; Assignment of a durable property power of attorney or health care power of attorney; and Your eligible children; and The eligible children of your domestic partner as described below. HIXGR

7 Aetna will rely upon your employer to determine whether or not a person meets the definition of a dependent for coverage under the plan. This determination will be conclusive and binding upon all persons for the purposes of this plan. Coverage for Children To be eligible for coverage, a child must be: Under 26 years of age; and If required, approved by the Maryland Health Benefit Exchange. An eligible child includes: Your biological children. Your stepchildren. Your legally adopted children. Your foster children, including any children placed with you for foster care or adoption. Any children for whom you are responsible under court order or for whom guardianship has been granted by a court of testamentary appointment. Your grandchildren in your court-ordered custody. Any child dependent of your domestic partner. Coverage for Incapacitated Children A dependent also includes an unmarried child who is chiefly dependent upon you for his or her support and at the time of reaching the limiting age is incapable of self-support because of a mental or physical incapacity that began before the child attained the limiting age. Coverage for an incapacitated child may be continued past the age limits shown above. See Incapacitated Dependent Children for more information. Important Reminder Keep in mind that you cannot receive coverage under this Plan as: Both an employee and a dependent; or A dependent of more than one employee. How And When To Enroll Initial Enrollment In The Plan You will be provided with plan benefit and enrollment information when you first become eligible to enroll. To complete the enrollment process, you will need to provide all requested information for yourself and your eligible dependents. You will also need to agree to make required contributions, if any, for any contributory coverage. Your employer will determine the amount of your plan contributions, if any, which you will need to agree to before you can enroll. Remember plan contributions, if any, are subject to change. You will need to enroll within 31 days of your eligibility date. Otherwise, you may be considered a Late Enrollee. If you miss the enrollment period, you will not be able to participate in the plan until the next annual enrollment period, unless you qualify under a Special Enrollment Period, as described below. Newborns are automatically covered for 31 days after birth; newly adopted children are covered for 31 days from the date of adoption; and minors for whom guardianship has been granted by court or testamentary appointment are covered for 31 days from the date of appointment. If, to continue coverage after 31 days, an additional premium is required for the addition of such child, you will need to complete a change form and return it to your employer within the 31-day enrollment period. HIXGR

8 Date of adoption means the earlier of: (1) a judicial decree of adoption; or (2) the assumption of custody, pending adoption, of a prospective adoptive child by a prospective adoptive parent. Special Exception: Please note that eligible employees who are Native American Indians may change plans on the Exchange once per month. Late Enrollment If you do not enroll during the Initial Enrollment Period, or a subsequent annual enrollment period, you and your eligible dependents may be considered Late Enrollees and coverage may be deferred until the next annual enrollment period. If, at the time of your initial enrollment, you elect coverage for yourself only and later request coverage for your eligible dependents, they may be considered Late Enrollees. You must return your completed enrollment form before the end of the next annual enrollment period. However, you and your eligible dependents may not be considered Late Enrollees under the circumstances described in the Special Enrollment Periods section below. Annual Enrollment(GR-9N HRPA MD) During the annual enrollment period of not less than 30 days, you will have the opportunity to review your coverage needs for the upcoming year. During this period, you have the option to change your coverage. The choices you make during this annual enrollment period will become effective the following year. If you do not enroll yourself or a dependent for coverage when you first become eligible, but wish to do so later, you will need to do so during the next annual enrollment period, unless you qualify under one of the Special Enrollment Periods, as described below. Special Enrollment Periods You will not be considered a Late Enrollee if you qualify under a Special Enrollment Period as defined below. If one of these situations applies, you may enroll before the next annual enrollment period. Loss of Other Health Care Coverage You or your dependents may qualify for a Special Enrollment Period if: You did not enroll yourself or your dependent when you first became eligible or during any subsequent annual enrollments because, at that time: You or your dependents were covered under another plan; and You refused coverage and, if your employer required it, you stated, in writing, at the time you refused coverage that the reason was that you or your dependents had other coverage; and You or your dependents are no longer eligible for the other coverage because of one of the following: The end of your employment; A reduction in your hours of employment (for example, moving from a full-time to part-time position);employer contributions toward that coverage have ended; The employer s decision to stop offering the group health plan to the eligible class to which you belong; The ending of the other plan s coverage; COBRA coverage ends; Death; Divorce or legal separation;cessation of a dependent s status as an eligible dependent as such is defined under this Plan; HIXGR

9 With respect to coverage under Medicaid or an S-CHIP Plan, which does not require that you submit a written statement to your employer, you or your dependents no longer qualify for such coverage; or You or your dependents have reached the lifetime maximum of another plan for all benefits under that plan. You or your dependents become eligible for premium assistance, with respect to coverage under the group health plan, under Medicaid or an S-CHIP Plan. You and your dependents experience one of the following triggering events : - You or your dependent loses minimum essential coverage, which includes loss of pregnancy related coverage under section 1902(a)(10)(A)(i)(IV) and (a)(10)(a)(ii)(ix) of the Social Security Act (Medicaid) by you or your dependent and loss of medically needed coverage under section 1902(a)(10)(C) once per Plan Year or while you or your dependent are enrolled in any non-plan Year group health plan or individual health insurance, even if you or your dependent have the option to renew such coverage. The date of the loss of coverage is the last day of the plan or policy year. (Loss of coverage does not include termination or loss due to: 1) failure to pay premiums on a timely basis, including COBRA coverage; or 2) situations allowing for rescission); - You or your dependent are enrolled in another qualified plan in the SHOP Exchange and you demonstrate to the Exchange that the qualified plan substantially violated a material provision of its contract in relation to you or your dependent; - You or your dependent gain access to new qualified health plans due to a permanent move; - You or your dependent demonstrate to the Exchange that you meet other exceptional circumstances as the SHOP exchange may provide; The Exchange determines that your or your dependents enrollment or non-enrollment was unintentional, inadvertent or erroneous and the result of an error, misrepresentation, misconduct or inaction of an officer, employee, or agent of the SHOP Exchange or HHS, its instrumentalities, or a non-exchange entity providing enrollment assistance or conducting enrollment activities; - It has been determined by the Exchange that you or your dependents, were not enrolled in QHP coverage; were not enrolled in the QHP you selected; or were eligible for but were not receiving advance payments of the premium tax credit or cost-sharing reductions as a result of misconduct on the part of a non-exchange entity providing enrollment assistance or conducting enrollment activities; or You or your dependent are enrolled in an employer-sponsored health benefit plan that is not qualifying coverage in an eligible employer-sponsored plan and you or your dependent are allowed to terminated existing coverage. You will need to enroll yourself or a dependent for coverage within: 60 days of when other coverage ends; 30 days for the Exchange triggering events ; within 60 days of when coverage under Medicaid or an S-CHIP Plan ends; within 60 days of the date you or your dependents become eligible for Medicaid or S-CHIP premium assistance; or at least 60 days before the end of your or your eligible dependent s coverage under the employer-sponsored plan that is not qualifying coverage and you or your dependent are allowed to terminate. Coverage under this option only applies to health benefit plans offered by a carrier in the SHOP Exchange. Your spouse, domestic partneror your dependents may qualify for a Special Enrollment Period without evidence of insurability if: You are enrolled under this plan; and Your spouse, domestic partner or your dependents are covered under your spouse s or domestic partner s plan; and Your spouse or domestic partner loses coverage under that plan because of the involuntary termination of your spouse s or domestic partner s employment other than for cause. In order for your spouse, domestic partner or dependent children to be covered under this plan, you must enroll them within 6 months after the date on which the group coverage of your spouse or domestic partner terminates. HIXGR

10 Evidence of termination of other coverage must be provided to Aetna. If you do not enroll during this time, you will need to wait until the next annual enrollment period. New Dependents You and your dependents may qualify for a Special Enrollment Period if: You did not enroll when you were first eligible for coverage; and You later acquire a dependent, as defined under the plan, through marriage, birth, adoption, placement for adoption, placement for foster care or through a child support order or other court order; and You elect coverage for yourself and your dependent within 60 days of acquiring the dependent. Your spouse or domestic partner and dependents may qualify for a Special Enrollment Period if: You enrolled when you were first eligible for coverage; and You later acquire a dependent, as defined under the plan, through marriage, birth, adoption, placement for adoption, placement for foster care or through a child support order or other court order; and With respect to your spouse or domestic partner, he or she is otherwise eligible for coverage at the birth, adoption, placement for adoption, placement for foster care of a child or through a child support order or other court order; and You elect coverage for your spouse or domestic partner and dependent within 60 days of acquiring the dependent. You will need to report any new dependents by completing a change form, which is available from your employer. The form must be completed and returned to Aetna within 60 days of the change. If you do not return the form within 60 days of the change, you will need to make the changes during the next annual enrollment period. Your dependent children may qualify for a Special Enrollment Period without evidence of insurability if: You are enrolled under this plan; and Your dependent children previously were covered under your spouse s or domestic partner s plan and your spouse or domestic partner died. In order for your dependent children to be covered under this plan, you must enroll them within 6 months after the death of your spouse or domestic partner. At the option of the Maryland Health Benefit Exchange, if you are an eligible employee or the spouse of an eligible employee and you lose a dependent or are no longer considered to be a dependent due to divorce or legal separation; or the eligible employee or eligible employee s dependent dies, you may qualify for a Special Enrollment Period. You will need to elect coverage within 60 days of the divorce, legal separation or death. When You Receive a Qualified Child Support Order A Qualified Medical Child Support Order (QMCSO) is a court order requiring a parent to provide health care coverage to one or more children. Your plan will provide coverage for a child who is covered under a QMCSO, if: You are enrolled under this plan and subject to a QMCSO requiring you to provide health expense coverage for a dependent child that meets the plan s eligibility requirements, your eligible dependent child shall be enrolled as a covered dependent within 60 business days after the plan s receipt of a complete medical support notice from your employer. You are not enrolled and eligible for coverage under this plan, and you are required by a QMCSO to provide health insurance coverage for your eligible dependent child, the plan shall enroll you and any eligible dependent children without regard to enrollment period restrictions within 60 business days after receipt of the complete medical support notice from your employer. HIXGR

11 You are enrolled under this plan and subject to a QMCSO requiring you to provide health expense coverage for a dependent child that meets the plan s eligibility requirements, and your eligible dependent child is not enrolled, the plan shall enroll such child upon application for enrollment by the non-insuring parent, child support enforcement agency, or Department of Health and Mental Hygiene regardless of enrollment period restrictions. Such coverage will remain in effect until written evidence is provided to the plan that: i. the order is no longer in effect; ii. your dependent child has been or will be enrolled under other reasonable health insurance coverage that will take effect on or before the effective date of the termination; iii. your employer has eliminated dependent coverage for all of its employees; iv. you are no longer employed by your employer at the time of the order, except that if you elect to exercise the provisions of COBRA coverage shall be provided for the dependent child consistent with your employer s plan. Under a QMCSO, if you are the non-custodial parent, the custodial parent may file claims for benefits. Benefits for such claims will be paid to the custodial parent. Under a QMCSO, if you are the non-insuring custodial parent, Aetna will provide you with membership cards, claim forms, and any other information necessary for the dependent child to obtain benefits; and process claim forms and make payment to you, the health care provider, or the Department of Health and Mental Hygiene, if you incur covered expenses for health care provided to your dependent child. Except as noted in the How and When to Enroll section above and the When Your Coverage Begins section below, coverage will be effective: i. in the case of marriage, on the date the completed request for enrollment is received; ii. in the case of a newborn, on the date of birth; iii. in the case of adoption, on the date of the child's adoption or placement for adoption, whichever occurs first; iv. in the case of court ordered coverage of a spouse, domestic partner or dependent, on the date of the court order; v. in the case of loss of coverage under COBRA continuation, on the date COBRA continuation ended; and vi. in the case of loss of coverage for other reasons, the date on which the applicable event occurred. When Your Coverage Begins Your Effective Date of Coverage The Effective Date of Coverage will be the date determined by the Maryland Health Connection in accordance with standards established by applicable laws and regulations, including 45 C.F.R. sections 155 and 156 as amended. If you do not return your completed enrollment information within 31 days of your eligibility date, the rules under the Special or Late Enrollment Periods section will apply. Important Notice: You must pay the required contribution if any in full. Your Dependent s Effective Date of Coverage Your dependent s coverage takes effect on the same day that your coverage becomes effective, if you have enrolled them in the plan. HIXGR

12 Note: If a new dependent affects your contributions, you will need to report them to Aetna within 31 days of their eligibility date. If you do not report the new dependent within 31 days of his or her eligibility date, the rules under the Special or Late Enrollment Periods section will apply. Effective Dates of Coverage for Individuals Who Enroll During a Special Enrollment Period a. In the case of loss of minimum essential coverage, loss of pregnancy related coverage or loss of medical needy coverage, loss of coverage under a non-plan Year group or individual plan, or gaining access to new plans due to a permanent move, the effective date is based on date of plan selection. If plan selection is made on or before loss of coverage, new coverage becomes effective the first of the following month. If plan selection occurs after the date of loss of coverage, new coverage becomes effective the first day of the following month when a selection is made between the 1st and 15th day of any month; and the first day of the second following month when a selection is made between the 16 th and the last day of any month. b. In the case of birth, adoption, placement for adoption, or placement in foster care, the effective date is the date of birth, adoption, placement for adoption or placement in foster care. c. In the case of a court order, the effective date is the date the court order is effective or if permitted by the Exchange the individual may elect a coverage effective date of the first day of the following month when a selection is received between the 1 st and the 15 th of any month; and the first day of the second following month when a selection is received between the 16 th and the last day of the month. d. In the case of marriage, the effective date is the first day of the month following plan selection. e. In the case of an individual eligible for special enrollment when: i. enrollment or non-enrollment was unintentional, inadvertent or erroneous and the result of an error, misrepresentation, misconduct, or inaction of an officer, employee, or agent of the Exchange or HHS, its instrumentalities, or a non-exchange entity providing enrollment assistance or conducting enrollment activities; ii. the qualified plan substantially violated a material provision of its contract with the individual; or iii. the individual meets other exceptional circumstances: For Exchange plans, the effective date is an appropriate date based on the specific circumstances and is determined by the Exchange. f. In the case of an individual or dependent who dies, the first day of the month following the plan selection, or if permitted by the Exchange the individual may elect a coverage effective date of the first day of the following month when a selection is received between the 1 st and the 15 th of any month; and the first day of the second following month when a selection is received between the 16 th and the last day of the month. g. For all other triggering events for Exchange plans, the first day of the following month when a selection is received by the Exchange between the 1st and 15th day of any month; and the first day of the second following month when a selection is received by the Exchange between the 16th and the last day of any month. HIXGR

13 How Your Medical Plan Works Common Terms Accessing Providers It is important that you have the information and useful resources to help you get the most out of your Aetna medical plan. This Booklet-Certificate explains: Definitions you need to know; How to access care, including procedures you need to follow; What expenses for services and supplies are covered and what limits may apply; What expenses for services and supplies are not covered by the plan; How you share the cost of your covered services and supplies; and Other important information such as eligibility, complaints and appeals, termination, continuation of coverage, and general administration of the plan. Important Notes Unless otherwise indicated, you refers to you and your covered dependents. Your health plan pays benefits only for services and supplies described in this Booklet-Certificate as covered expenses that are medically necessary. This Booklet-Certificate applies to coverage only and does not restrict your ability to receive health care services that are not or might not be covered benefits under this health plan. Store this Booklet-Certificate in a safe place for future reference. Common Terms Many terms throughout this Booklet-Certificate are defined in the Glossary section at the back of this document. Defined terms appear in bolded print. Understanding these terms will also help you understand how your plan works and provide you with useful information regarding your coverage. About Your PPO Medical Plan This Preferred Provider Organization (PPO) medical plan provides coverage for a wide range of medical expenses for the treatment of illness or injury. It does not provide benefits for all medical care. The plan also provides coverage for certain preventive and wellness benefits. With your PPO plan, you can directly access any physician, hospital or other health care provider (network or out-of-network) for covered services and supplies under the plan. The plan pays benefits differently when services and supplies are obtained through network providers or out-of-network providers. The plan will pay for covered expenses up to the maximum benefits shown in this Booklet-Certificate. Coverage is subject to all the terms, policies and procedures outlined in this Booklet-Certificate. Not all medical expenses are covered under the plan. Exclusions and limitations apply to certain medical services, supplies and expenses. Refer to the What the Plan Covers, Exclusions, Limitations and Schedule of Benefits sections to determine if medical services are covered, excluded or limited. HIXGR

14 This PPO plan provides access to covered benefits through a network of health care providers and facilities. These network providers have contracted with Aetna, an affiliate or third party vendor to provide health care services and supplies to Aetna plan members at a reduced fee called the negotiated charge. This PPO plan is designed to lower your out-of-pocket costs when you use network providers for covered expenses. Your cost-sharing will generally be lower when you use network providers and facilities. Your out-of-pocket costs may vary between network and out-of-network benefits. Read your Schedule of Benefits carefully to understand the cost sharing charges applicable to you. Availability of Providers Aetna cannot guarantee the availability or continued participation of a particular provider. Either Aetna or any network provider may terminate the provider contract or limit the number of patients accepted in a practice. If the physician initially selected cannot accept additional patients, you will be notified and given an opportunity to make another selection. Ongoing Reviews Aetna conducts ongoing reviews of those services and supplies which are recommended or provided by health professionals to determine whether such services and supplies are covered benefits under this Booklet-Certificate. If Aetna determines that the recommended services or supplies are not covered expenses, you will be notified. You may appeal such determinations by contacting Aetna to seek a review of the determination. Please refer to the Reporting of Claims section of this Booklet-Certificate and the Appeals Procedure provision included with this Booklet- Certificate. To better understand the choices that you have with your PPO plan, please carefully review the following information. Important Note ID Card: You will receive an ID card. It identifies you as a member when you receive services from health care providers. If you have not received your ID card or if your card is lost or stolen, notify Aetna immediately and a new card will be issued. How Your PPO Medical Plan Works Accessing Network Providers and Benefits You may select any network provider from the network provider directory or by logging on to Aetna s website at You can search Aetna s online directory, DocFind, for names and locations of physicians and other health care providers and facilities. If a service or supply you need is covered under the plan but not available from a network provider or hospital in your area, please contact Member Services by or at the toll-free number on your ID card for assistance. Certain health care services such as hospitalization, outpatient surgery and certain other outpatient services, require precertification with Aetna to verify coverage for these services. You do not need to precertify services provided by a network provider. Network providers will be responsible for obtaining the necessary precertification for you. Since precertification is the provider s responsibility, there is no additional out-ofpocket cost to you as a result of a network provider s failure to precertify services. Refer to the Understanding Precertification section for more information. You will not have to submit medical claims for treatment received from network providers. Your network provider will take care of claim submission. Aetna will directly pay the network provider or facility less any cost sharing required by you. You will be responsible for deductibles, coinsurance and copayments, if any. HIXGR

15 You will receive notification of what the plan has paid toward your covered expenses. It will indicate any amounts you owe towards your deductible, copayment, or coinsurance or other non-covered expenses you have incurred. You may elect to receive this notification by , or through the mail. Call or Member Services if you have questions regarding your statement. Cost Sharing For Network Benefits You share in the cost of your benefits. Cost Sharing amounts and provisions are described in the Schedule of Benefits. Network providers have agreed to accept the negotiated charge. Aetna will reimburse you for a covered expense, incurred from a network provider, up to the negotiated charge and the maximum benefits under this Plan, less any cost sharing required by you such as deductibles, copayments and coinsurance. Your coinsurance is based on the negotiated charge. You will not have to pay any balance bills above the negotiated charge for that covered service or supply. You must satisfy any applicable deductibles before the plan will begin to pay benefits. Deductibles and coinsurance are usually lower when you use network providers than when you use out-ofnetwork providers. For certain types of services and supplies, you will be responsible for any copayments shown in the Schedule of Benefits. The copayments will vary depending upon the type of service. After you satisfy any applicable deductible, you will be responsible for any applicable coinsurance for covered expenses that you incur. You will be responsible for your coinsurance up to the maximum out-of-pocket limit applicable to your plan. Once you satisfy any applicable maximum out-of-pocket limit, the plan will pay 100% of the covered expenses that apply toward the limit for the rest of the Plan Year. Certain designated out-of-pocket expenses may not apply to the maximum out-of-pocket limit. Refer to the Schedule of Benefits for information on what expenses do not apply and for the specific maximum out-of-pocket limit amounts that apply to your plan. The plan will pay for covered expenses up to the maximum limits shown in the Schedule of Benefits and Booklet- Certificate. You are responsible for any expenses incurred over those maximum limits. You may be billed for any deductible, copayment, or coinsurance amounts, or any non-covered expenses that you incur. Accessing Out-of-Network Providers and Benefits You have the choice to access licensed providers, hospitals and facilities outside the network for covered benefits. You will still be covered when you use out-of-network providers for covered expenses. Your cost-sharing is usually higher when you utilize out-of-network providers. Except for out-of-network on-call and hospital-based physicians who have accepted assignment, out-of-network providers who have not agreed to accept the negotiated charge may balance bill you for charges over the amount Aetna pays under the plan. Aetna will only pay up to the recognized charge. Special Exception If you have been diagnosed with a condition or disease that requires specialized health care services or medical care and Aetna does not have in its provider network a specialist or non-physician specialist with the professional training and expertise to treat or provide health care services for the condition or disease; or Aetna cannot provide reasonable access to the specialist or non-physician specialist with the professional training and expertise to treat or provide health care services for the condition or disease without unreasonable delay or travel, then you may request a referral from Aetna to a specialist or non-physician specialist who is not part of Aetna s provider network. If Aetna approves your request, then Aetna will treat the services that you receive as if they were provided by a network provider and will calculate any applicable deductible, copayment amount, or coinsurance as having been provided innetwork. HIXGR

16 Precertification is necessary for certain services. When you receive services from an out-of-network provider, you are responsible for obtaining the necessary precertification from Aetna. Your provider may precertify your treatment for you, however you should verify with Aetna prior to the procedure, that the provider has obtained precertification from Aetna. If your treatment is not precertified, the benefit payable may be significantly reduced. You must call the precertification toll-free number on your ID card to precertify services. Refer to the Understanding Medical Precertification section for more information on the precertification process and what to do if your request for precertification is denied. When you use out-of-network providers, you may have to pay for services at the time that they are rendered. You may be required to pay the full charges. When you pay an out-of-network provider directly, you must submit a completed claim form and proof of payment to Aetna to receive reimbursement of covered expenses from Aetna. Aetna will reimburse you for a covered expense up to the recognized charge, less any cost sharing required of you by your plan. Refer to the General Provisions section of this Booklet-Certificate for details of how to file a claim under this plan. Except for out-of-network on-call and hospital-based physicians who have accepted assignment or in the case of a special exception as noted above, if your out-of-network provider charges more than the recognized charge, you will be responsible for any expenses incurred above the recognized charge. You will receive notification of what the plan has paid toward your covered expenses. It will indicate any amounts you owe towards any deductible, coinsurance or other non-covered expenses you have incurred. You may elect to receive this notification by , or through the mail. Call or Member Services if you have questions regarding your statement. Important Note Failure to precertify services and supplies provided by an out-of-network provider will result in a reduction of benefits under this Booklet-Certificate. Please refer to the Understanding Medical Precertification section of this Booklet- Certificate for information on how to request precertification. Cost Sharing for Out-of-Network Benefits You share in the cost of your benefits. Cost Sharing amounts and provisions are described in the Schedule of Benefits. Out-of-network providers have not agreed to accept the negotiated charge. Aetna will reimburse you for a covered expense, incurred from an out-of network provider, up to the recognized charge and the maximum benefits under this Plan, less any cost-sharing required by you such as deductibles and coinsurance. The recognized charge is the maximum amount Aetna will pay for a covered expense from an out-of-network provider. Your coinsurance is based on the recognized charge. Except for out-of-network on-call and hospital-based physicians who have accepted assignment, if your out-of-network provider charges more than the recognized charge, you will be responsible for any expenses incurred above the recognized charge. Except for emergency services, Aetna will only pay up to the recognized charge. You must satisfy any applicable deductibles before the plan begins to pay benefits. Deductibles and coinsurance are usually higher when you use out-of network providers than when you use network providers. After you satisfy any applicable deductible, you will be responsible for any applicable coinsurance for covered expenses that you incur. You will be responsible for your coinsurance up to the maximum out-of-pocket limit applicable to your plan. Your coinsurance will be based on the recognized charge. If the health care provider you select charges more than the recognized charge and they are not an out-of-network on-call or hospital-based physician who has accepted assignment, you will be responsible for any expenses above the recognized charge. HIXGR

17 Once you satisfy any applicable maximum out-of-pocket limit, the plan will pay 100% of the covered expenses that apply toward the limit for the rest of the Plan Year. Certain designated out-of-pocket expenses may not apply to the maximum out-of-pocket limit. Refer to the Schedule of Benefits for information on what expenses do not apply and for the specific maximum out-of-pocket limit amounts that apply to your plan. The plan will pay for covered expenses up to the maximum limits shown in the Schedule of Benefits and Booklet- Certificate. You are responsible for any expenses incurred over those maximum limits. Continuity of Care If you are a new enrollee and your current provider does not have a contract with Aetna, you may continue an ongoing course of treatment with your current provider for the following conditions: acute conditions; serious chronic conditions; pregnancy; mental health conditions and substance use disorders; and any other condition for which the provider and Aetna reach agreement, for a transitional period of: up to 90 days; and in the case of pregnancy, the duration of the three trimesters of pregnancy, including the period of time that postpartum care directly related to the delivery is provided; beginning on the effective date of enrollment. If you are an individual transitioning from the Maryland Medical Assistance Program to Aetna, and you are currently receiving behavioral health or dental benefits under that program, which have been authorized by the Maryland Medical Assistance Program s third-party administrator, or you are an individual transitioning from another carrier or managed care organization to Aetna, then, at your or your parent s, guardian s, designee s or health care provider s request, Aetna will accept the third-party administrators, relinquishing carriers or managed care organizations preauthorization for the procedures, treatments, medications, or services you are receiving and which are covered by Aetna for the lesser of the course of treatment or 90 days; and the duration of the three trimesters of a pregnancy and the initial post-partum visit. The third-party administrator, relinquishing carrier or managed care organization shall provide Aetna with a copy of the pre-authorization within 10 days of your request. You need to complete a Transition of Coverage Request form and send it to Aetna. Contact Member Services at the number on the back of your ID card for a copy of this form. If authorized by Aetna, coverage will be provided for the transitional period but only if the provider agrees to: Accept reimbursement: at the rate approved by the Health Services Cost Review Commission (HSCRS) for hospitals; at the rate applicable to Federally Qualified Health Centers under section 1302(g) of the Affordable Care Act; at the negotiated charge (the rate the network provider accepts for similar services provided in the same or similar geographic area)for providers; or at an alternative rate agreed to by the provider and Aetna; and that includes the enrollees cost-sharing, which will be the same as required if the enrollee were receiving services from a network provider, and which (the reimbursement rate and enrollee costsharing) are established by Aetna prior to the start of the transitional period, as payment in full; Adhere to quality standards and to provide medical information related to such care; and Adhere to Aetna s policy and procedures. If the provider does not agree to a rate and compensation method with Aetna then, unless the enrollee has assigned their benefits to the provider, Aetna will transition the enrollee to a network provider. This provision shall not be construed to require Aetna to provide coverage for benefits not otherwise covered under this Booklet-Certificate. HIXGR

18 Understanding Medical Precertification Precertification Certain services and supplies, such as inpatient stays, certain tests, procedures and outpatient surgery require precertification by Aetna. Precertification is a process that helps you and your physician determine whether the services being recommended are covered expenses under the plan. It also allows Aetna to help your provider coordinate your transition from an inpatient setting to an outpatient setting (called discharge planning), and to register you for specialized programs or case management when appropriate. You do not need to precertify services and supplies provided by a network provider. Network providers will be responsible for obtaining necessary precertification for you. Since precertification is the network provider s responsibility, there is no additional out-of-pocket cost to you as a result of a network provider s failure to precertify services and supplies. When you go to an out-of-network provider, it is your responsibility to obtain precertification from Aetna for any services and supplies on the precertification list. If you do not precertify, your benefits may be reduced, or the plan may not pay any benefits. The list of services and supplies requiring precertification appears later in this section. Important Note Please read the following sections in their entirety for important information on the precertification process, and any impact it may have on your coverage. The Precertification Process Prior to being hospitalized or receiving certain other medical services or supplies there are certain precertification procedures that must be followed. You do not need to precertify services and supplies provided by a network provider. You are responsible for obtaining precertification for services and supplies provided by an out-of-network provider. You or a member of your family, a hospital staff member, or the attending physician, must notify Aetna to precertify the admission or medical services and expenses prior to receiving any of the services or supplies that require precertification pursuant to this Booklet-Certificate in accordance with the following timelines: Precertification should be secured within the timeframes specified below. To obtain precertification, call Aetna at the telephone number listed on your ID card. This call must be made: For non-emergency admissions: You, your physician or the facility will need to call and request precertification at least 14 days before the date you are scheduled to be admitted. For an emergency admission: You, your physician or the facility must call within 48 hours or as soon as reasonably possible after you have been admitted. For an urgent admission: You, your physician or the facility will need to call before you are scheduled to be admitted. An urgent admission is a hospital admission by a physician due to the onset of or change in an illness; the diagnosis of an illness; or an injury. For outpatient non-emergency medical services requiring precertification: You or your physician must call at least 14 days before the outpatient care is provided, or the treatment or procedure is scheduled. HIXGR