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: Colorado 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 Colorado. 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 Colorado, and if the benefit value exceeds those benefits covered under the group policy and booklet certificate. In regards to your Open Choice, Open Choice High Deductible Health Plan, Open Access Managed Choice High Deductible Health Plan, and Open Access Managed Choice Plans: Notice: As to residents of Colorado, below is a list of counties in Colorado where Aetna has contracted with Preferred Care Providers* to provide medical coverage under this Plan at the time this information was prepared: ADAMS ACADIA ALAMOSA ARAPAHOE BACA BOULDER CHAFFEE CLEAR CREEK DELTA DENVER DOUGLAS EAGLE EL PASO ELBERT FRANKLIN FREMONT GARFIELD GILPIN GRAND 1

2 HUERFANO JEFFERSON KIT CARSON LAKE LARIMER LAS ANIMAS LINCOLN LOGAN MESA MOFFAT MONTROSE MORGAN OTERO PHILLIPS PITKIN PROWERS PUEBLO ROUTT SUMMIT TELLER WASHINGTON WELD YUMA MULTNOMAH * For up-to-date information regarding Preferred Care Providers, please refer to your Provider Directory or visit DocFind, Aetna s electronic provider directory, at While Aetna s goal is to provide accurate information, provider network composition is subject to change without notice because a provider may terminate its contract, Aetna may terminate the provider s contract, or for other reasons. In addition, present or future participation by a particular provider cannot be guaranteed for Preferred or in-network benefits. Before receiving services, members should always verify that the providers they choose are participating in our network. Dependents You may cover your: wife or husband; and unmarried children who are under 19 years of age. Any other unmarried child under age 24 who goes to school on a regular basis and depends solely on you for support will be covered as a dependent. An eligible dependent child includes: Your biological children; Your stepchildren; Your legally adopted children; Your foster children, including any children placed with you for adoption; Any children for whom you are responsible under court order; 2

3 Your grandchildren in your court-ordered custody; and Any other child who lives with you in a parent-child relationship. Coverage for a handicapped child may be continued past the age limits shown above. See Handicapped Dependent Children for more information. In regards to your Open Access Managed Choice High Deductible Health Plan and Open Access Managed Choice Plans: If a person incurs Covered Medical Expenses which: are for services and supplies that are not reasonably available from a Preferred Care Provider, as determined by Aetna; and are expenses for which benefits would be paid at a Preferred Care rate, if provided by a Preferred Care Provider; such expenses will be deemed to be expenses incurred for Preferred Care. As to Preferred Care expenses; if you are responsible for a coinsurance payment based on a percentage of the bill, where applicable, your obligation will be determined based upon the negotiated charge established by contract with Aetna for that service or supply, either directly or indirectly through a third party, rather than the amount the provider would bill in the absence of a negotiated charge. For questions regarding Non-Preferred Care Provider reimbursement rates, please contact the Member Services tollfree number on your ID Card. This Calendar Year Deductible applies to all expenses except: The following expenses incurred for Preferred Care: Child Health Supervision Services Expenses For Child Health Supervision Services Expenses Refer to applicable category of "Physician Fees" in your Summary of Coverage. Additional Other Medical Expenses Charges made by a physician (including those incurred for telemedicine in accordance with any applicable state or federal law). Cervical Cancer Immunization Even though not incurred in connection with a disease or injury, Covered Medical Expenses include charges incurred for One Cervical Cancer Immunization for females up to the age limitations recommended by, and for whom a vaccination is recommended by, the Advisory Committee on Immunization Practices of the United States Department of Health and Human Services. Charges for the full cost of the immunization are payable under the Plan. 3

4 In regards to your Open Choice, Open Choice High Deductible Health Plan, Open Access Managed Choice High Deductible Health Plan, and Open Access Managed Choice Plans: Screening for Cancer of the Prostate Even though not incurred in connection with a disease or injury, Covered Medical Expenses include charges incurred by a male age 40 or over in connection with a digital rectal exam for routine screening for cancer of the prostate, including a prostate specific antigen (PSA) test. This Calendar Year Deductible applies to all expenses except: The following expenses incurred for Preferred Care: Covered Medical Expenses incurred for routine screening for cancer of the prostate Treatment of Mental Disorders Charges incurred for the treatment of a mental disorder on an inpatient or an outpatient basis are Covered Medical Expenses to the same extent as charges incurred for the treatment of any other disease. Hospital This is a place that: Mainly provides inpatient facilities for the surgical and medical diagnosis, treatment, and care of injured and sick persons. Is supervised by a staff of physicians. Provides 24 hour a day R.N. service. Is not mainly a place for rest, for the aged, for drug addicts, for alcoholics, or a nursing home. Makes charges. Is currently licensed or certified by the Colorado Department of Health and Environment. Cleft Lip and Cleft Palate Rule Coverage for the treatment of a cleft lip or cleft palate is provided as follows: Dental related oral surgery of a cleft lip or cleft palate for a child under age 18 is covered as a Type C Service. If coverage for orthodontic treatment is not otherwise specified in the Booklet-Certificate, orthodontic treatment of a cleft lip or cleft palate for a child under 18 is covered as a Type C Service. Ronald A. Williams Chairman, Chief Executive Officer, and President Aetna Life Insurance Company (A Stock Company) 4

5 Aetna Life Insurance Company Hartford, Connecticut Amendment Policyholder: THE TLC COMPANIES Group Policy No.: GP This Certificate Amendment describes a change in your Certificate, which applies to group policies providing medical coverage issued by Aetna Life Insurance Company in the State of Colorado. It also applies to Colorado residents covered under a group policy providing medical coverage and issued by Aetna Life Insurance Company in a state other than Colorado. The purpose of this Certificate Amendment is to add this provision to your Certificate if it is not already included or to replace a corresponding provision which is included but which provides a lesser benefit or coverage. Keep this Certificate Amendment with your Certificate at all times. This Certificate Amendment is effective on the later of the date you become covered under the group policy and January 1, The following information has been added to your medical Booklet-Certificate: Cervical Cancer Immunization Even though not incurred in connection with a disease or injury, Covered Medical Expenses include charges incurred for One Cervical Cancer Immunization for females up to the age limitations recommended by, and for whom a vaccination is recommended by, the Advisory Committee on Immunization Practices of the United States Department of Health and Human Services. Charges for the full cost of the immunization are payable under the Plan Ronald A. Williams Chairman, Chief Executive Officer, and President Rider: 1013 CO HB 1301-Cerivical Cancer Vaccine-Medical Issue Date: April 3, 2009 GR-8-CR1 1