Kansas and Missouri plan guide

Transcription

1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Kansas and Missouri plan guide The health of business, well planned. Plans effective September 1, 2012 For businesses with eligible employees KM (6/12)

2 KM (6/12) Team with Aetna for the health of your business Introducing a new suite of products and services designed specifically for companies with 2 to 100 eligible employees. Health insurance plans are underwritten by Aetna Life Insurance Company (Aetna). Dental benefits and insurance plans are offered and/or underwritten by Aetna Dental Inc. and/or Aetna Life Insurance Company. Life and disability insurance plans/policies are offered and/or underwritten by Aetna Life Insurance Company.

3 You can count on Aetna to provide health plans that help simplify decision making and plan administration so you can focus on the health of your business KM (6/12) Aetna is committed to helping employers build healthy businesses. In today s rapidly changing economy, we recognize the need for less expensive, less complex health plan choices. Now, Aetna offers a variety of newly streamlined medical and dental benefits and insurance plans to provide more affordable options and to help simplify plan selection and administration. In this guide: 5 Small business commitment 5 Benefits for every stage of life 6 Medical overview 10 Medical plan options 24 Dental overview 26 Dental plan options 39 Life & disability overview 42 Life & disability plan options 44 Underwriting guidelines 53 Product specifications 63 Limitations and exclusions 66 Group enrollment checklist 3

4 Employers and their employees can benefit from Affordable plan options Online self-service tools and capabilities Enhanced services for consumer-directed health plans 24-hour access to Employee Assistance Program services Preventive care covered 100% Aetna disease management and wellness programs With Aetna, we know it s about... Options We provide a variety of health insurance plan options to help meet your employees needs, including medical, dental, disability and life insurance. And, with access to a wide network of health care providers, you can be sure that employees have options in how they access their health care. Medical plans Consumer-directed health plans (CDHPs) HSA-compatible plans Traditional plans Dental plans DMO PPO PPO Max Freedom-of-Choice plan design option Preventive Life and disability plans Basic life Supplemental life AD&D Ultra Supplemental AD&D Ultra Dependent life Packaged life and disability plans Short term disability Long term disability Simplicity We know that the health of your business is your top priority. Aetna s streamlined plans and variety of services make it easier for you to focus on your business by simplifying administration and management. Aetna makes it easy to manage health insurance benefits with simplified enrollment, billing, and claims processing so you can focus on what matters most. Trust We work hard to provide health plan solutions you can trust. Our account executives, underwriters, and customer service representatives are committed to providing small businesses and their employees with service and care they can trust. Aetna resources are designed to fortify the health of your business Track medical claims and take advantage of online services with your Aetna Navigator secure member website. It features automated enrollment, personal health records, and printable temporary member ID cards. Get real cost and health information to help make the right care decision with an online Cost of Care Estimator. Manage health records online with the Personal Health Record. Use the Aetna Health Connections SM disease management program, which provides personal support to members to help them manage their conditions. Leverage 24/7 access to a nurse to help with personal health-related questions. Help members work toward health goals with wellness initiatives, such as the Simple Steps To A Healthier Life online program. Take advantage of discount* programs for vision, dental, and general health care that encourage use of plan offerings. *Discounts are NOT insurance and are not underwritten by Aetna. 4

5 Aetna is committed to the health of your business At Aetna, we understand that your business has unique needs. That s why we have streamlined our plan options for employers with 2 to 100 employees. We are committed to providing you with value and quality you can count on. Our variety of products and services allows you to focus on the health of your business. Aetna s health plan options are designed with the health of your business in mind Basic plans Basic benefits for your employees Limit the expense to your business Allow employees to buy up and share more of the cost --MO/KS OAMC $3,500 (EMB) 90/60 HSA Value plans Encouraging employee responsibility in their health care decisions Tools and resources to support consumerism Innovative plan design --MO/KS OAMC $5,000 (EMB) 90/60 HSA --MO/KS OAMC $5,000 70/50-12 Traditional plans Traditional benefits plans Limit the financial impact on employees --MO/KS OAMC $1,000 80/ MO/KS OAMC $1,500 80/ MO/KS OAMC $3, %-12 Health insurance benefits for every stage of life For young individuals and couples without children Lower monthly payments Modest out-of-pocket costs Quality preventive care Prescription drug coverage Financial protection...we offer: Consumer-directed health plans For married couples and single parents with teens and college-aged children Checkups and care for injuries and illness Preventive care and screenings that promote a healthy lifestyle National network of health care providers...we offer: Consumer-directed health plans Traditional plans For married couples and single parents with young children or teens Lower fees for office visits Lower monthly payments Caps on out-of-pocket expenses Quality preventive care for the entire family...we offer: Traditional plans For men and women 55 years of age and over with no children at home Financial security Quality prescription drug coverage Hospital inpatient/outpatient services Emergency care...we offer: Consumer-directed health plans Traditional plans 5

6 Aetna Medical Overview At Aetna, we are committed to putting the member at the center of everything we do. You can count on Aetna to provide health plans that help simplify decision making and plan administration so you can focus on the health of your business. 6

7 Medical Overview Missouri Provider Network* MC and PPO Adair Clinton Jackson Morgan St. Francois Andrew Cole Jasper Newton St. Genevieve Atchison Cooper Jefferson Nodaway St. Louis Audrain Crawford Knox Osage St. Louis City Barry Dade Laclede Ozark Stone Barton Dallas Lafayette Pettis Sullivan Bates Daviess Lawrence Phelps Taney Benton DeKalb Lewis Platte Texas Boone Dent Lincoln Polk Vernon Buchanan Douglas Linn Pulaski Warren Caldwell Franklin Livingston Putnam Washington Callaway Gasconade Macon Ralls Webster Camden Gentry Madison Randolph Worth Carroll Greene Maries Ray Wright Cass Grundy McDonald Saline Cedar Harrison Mercer Schuyler Chariton Henry Miller Scotland Christian Hickory Moniteau Shannon Clark Holt Monroe St. Charles Clay Howard Montgomery St. Clair Aetna Managed Choice Open Access plan For groups with employees primarily in Kansas and Missouri metropolitan areas (where the MC network is available). The Aetna Managed Choice Open Access plan provides members the advantages of a managed care plan while giving employees the flexibility to access any health care professionals without a referral. Members are able to receive emergency services at the in-network coinsurance/copay level. There are a variety of plans at different price points to meet the needs of each individual employee. Aetna Open Choice PPO For groups with employees in more rural areas of Kansas and Missouri, where Managed Choice POS Open Access is not available; also for out-of-state employees in a PPO service area. The Aetna PPO insurance plan offers members the freedom to go directly to any recognized provider for covered expenses, including specialists. If members choose a physician or hospital outside of the network, out-of-pocket costs will be higher. Members are able to receive emergency services at the in-network/copay level. No referrals are required. Kansas Provider Network* MC and PPO PPO only Allen Elk Leavenworth Russell Dickinson Anderson Ellsworth Lincoln Saline Ellis Atchison Finney Linn Sedgwick Jefferson Barton Ford Logan Seward Jewell Bourbon Franklin Marion Stafford Lyon Brown Geary McPherson Stanton Marshall Butler Graham Meade Stevens Osage Chase Grant Miami Sumner Pawnee Chautauqua Gray Montgomery Thomas Pottawatomie Cherokee Greeley Morris Trego Riley Cheyenne Greenwood Morton Washington Rooks Clark Hamilton Neosho Wichita Scott Clay Harper Ness Wilson Shawnee Cloud Harvey Osborne Woodson Smith Coffey Haskell Ottawa Wyandotte Comanche Hodgeman Phillips Cowley Johnson Pratt Crawford Kearny Reno Doniphan Kingman Republic Douglas Labette Rice *Network subject to change. 7

8 Multi-Option Offerings* Greater employee choice Employers can offer any 2 or 3 of the available plans. For groups of 51 to 100 enrolled employees, Triple Option is available as long as one of the plans is an HSA or HRA plan. Flexibility and affordability Employers can create a customized benefits package from any of our plan types and plan designs. Aetna offers a variety of plans at different price points. Employers may designate a level of contribution that meets their budget. Total freedom Aetna offers plan choices that range in price and benefits to meet each individual employee s needs, whether they are lower premiums or lower out-of-pocket costs at the time services are received. Easy administration Setting up this program is simple: 1. The employer chooses up to three plans to offer on the Employer Application. 2. The employer chooses how much to contribute. 3. Each employee chooses the plan that s right for him or her. Multi-Option Offerings Target audience Every small business with 5+ enrolled employees Plan choices -- Up to 3 of the available plans to 100 enrolled employees - Triple Option is available as long as one of the plans is an HSA or HRA plan. Minimum participation 2 to 4 enrolled employees Choice of one plan 5 to 50 enrolled employees Choice of up to 3 plans 51 to 100 enrolled employees Triple Option is available as long as one of the plans is an HSA or HRA plan. Employer contribution -- of employee-only premium or a minimum defined contribution of $120 per employee. -- Employer funding of the deductible in excess of will be subject to an underwriting rating adjustment. -- Coverage can be denied based on inadequate or excess contributions to 100 eligible employees - 75% of the employee-only premium or of the total group premium. Rating options 2 to 9 eligible employees Tabular 10 to 50 eligible employees Option of tabular or composite Health Reimbursement Account (HRA) The Aetna HealthFund HRA combines the protection of a deductible-based health plan with a health fund that pays for eligible health care services. The member cannot contribute to the HRA, and employers have control over HRA plan designs. The fund is available to an employee for qualified expenses on the plan s effective date. The HRA and the health savings account (HSA) provide members with financial support for higher out-of-pocket health care expenses. Aetna s consumer-directed health products and services give members the information and resources they need to help make informed health care decisions for themselves and their families while helping lower employers costs. Underlying plan policy Aetna considers an underlying plan to be any plan sponsor-funded arrangement or third-party plan or combination of them that, directly or indirectly, subsidizes, funds or reimburses or is available, directly or indirectly, to subsidize, fund or reimburse, any part of an insured s or enrollee s network deductible expenses. In setting the premium rate for benefits plans with network deductibles, Aetna assumes that an underlying plan may fund or less of an insured s or enrollee s network deductible. If the plan sponsor has an underlying plan available to fund in excess of, it is material to the development of pricing for coverage and will result in an additional load of 10% applied to the rates. As such, we require the plan sponsor to tell us if there will be any underlying plan in use during the plan year available to fund an insured s or enrollee s network deductible in excess of. In the event that a plan sponsor does not certify to the level of deductible funding, the 10% load will be applied to the rates. COBRA administration Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes that can assist employers with managing the complex billing and notification processes that are required for COBRA compliance while also helping to save them time and money. Section 125 Cafeteria Plans and Section 132 Transit Reimbursement Accounts Employees can reduce their taxable income, and employers can pay less in payroll taxes. There are three ways to save: Premium-only plans (POP) Employees can pay for their portion of the group health insurance expenses on a pretax basis. Flexible savings account (FSA) FSAs give employees a chance to save for health expenses with pretax money. Health care spending accounts allow employees to set aside pretax dollars to pay for out-of-pocket expenses as defined by the IRS. Dependent care spending accounts allow participants to use pretax dollars to pay child or elder care expenses. *Available to groups with five or more enrolled employees. 8

9 Transit reimbursement account (TRA) TRAs allow participants to use pretax dollars to pay transportation and parking expenses for the purpose of commuting to and from work. Administrative Fees Fee description Fee No-cost health incentive credit* Members can earn $50 in just a few simple steps Members earn a $50 credit toward their out-of-pocket expenses when they: --Complete or update their health assessment on Simple Steps To A Healthier Life, and --Complete one online wellness program If the employee s spouse is covered under the plan, he or she is also eligible for the same incentive credit. So a family could save $100 in out-of-pocket expenses each year. Incentive rewards will be credited toward the deductible and maximum out-of-pocket limit. This program is included at no additional cost on all plans except the HSA-compatible plans. Health Savings Account (HSA) No set-up or administrative fees The Aetna HealthFund HSA plan combines a high-deductible health insurance plan with a health savings accouunt. Once enrolled, account contributions can be made by the employee and/or employer. The HSA can be used to pay for qualified expenses tax free. Member s HSA Plan HSA Account Members own the HSA Contribute tax free Members choose how and when to use HSA dollars Roll it over each year and let it grow Earns interest, tax free Today Use for qualified expenses with tax free dollars Future Plan for future and retiree health-related costs High-deductible health plan Eligible in-network preventive care services will not be subject to the deductible Members pay 100% until deductible is met, then only pay a share of the cost Meet out-of-pocket maximum, then plan pays 100% HSA Initial set-up $0 Monthly fees $0 POP Initial set-up* $175 Renewal $100 HRA and FSA** fees Initial set-up 2 25 Employees $ Employees $ Employees $550 Renewal fee 1 25 Employees $ Employees $ Employees $325 Monthly fees*** $5.25 per participant Additional set-up fee for stacked plans $150 (those electing an Aetna HRA and FSA simultaneously) Participation fee for stacked participants $10.25 per participant Minimum fees 1 25 Employees $25 per month minimum Employees $50 per month minimum COBRA Annual fee Employees $ Employees $175 Per employee per month Employees $ Employees $1.02 Initial notice fee $1.50 per notice (includes notices at time of implementation and during ongoing administration) TRA Annual fee $350 Transit monthly fees Parking monthly fees $4.25 per participant $3.15 per participant * Non discrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle testing available at employer request for $100 fee. Nondiscrimination testing only available for FSA and POP products. ** Aetna FSA pricing is inclusive for POP. Debit cards are available for FSA only. Contact Aetna for further information. *** For HRA, if the employer opts out of Streamline, the fee is increased $1.50 per participant. For FSA, the debit card is available for an additional $1 per participant per month. Mailing reimbursement checks direct to employee homes is an additional $1 per participant per month. Not applicable to HSA-compatible plans. Aetna HRAs are subject to employer-defined use and forfeiture rules. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information subject to change. Aetna reserves the right to change any of the above fees and to impose additional fees upon prior written notice. 9

10 Aetna Managed Choice Open Access Plan Options MO/KS OAMC $500 90/60-12 MO/KS OAMC $ /50-12 PCP/Referrals Required No N/A No N/A Member Benefits In network Out of network 1 In network Out of network 1 Member Coinsurance 10% 40% 20% Calendar-Year Deductible (In-network and out-of-network expenses accumulate separately) $500 Individual $1,000 Family $1,000 Individual $2,000 Family $1,000 Individual $2,000 Family $2,000 Individual $4,000 Family Calendar-Year Out-of-Pocket Maximum (Includes deductible; Copayments and certain payments do not apply; Accumulates separately in network/out of network) $2,500 Individual $5,000 Family $6,000 Individual $12,000 Family $3,000 Individual $6,000 Family $8,000 Individual $16,000 Family Deductible and Out-of-Pocket Maximum Accumulation Embedded 2 Embedded 2 Lifetime Maximum Benefit Unlimited Unlimited Primary Physician Office Visit Specialist Office Visit Walk-In Clinics Outpatient Lab Outpatient X-ray Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET scan; precertification required) Physical Exams - Adults (Age and frequency schedules apply) Well-Child Exams (Age and frequency schedules apply) Routine GYN (Frequency schedules apply) $25 copay; $50 copay; $25 copay; $25 copay; $50 copay; 40% $30 copay; 40% $60 copay; 40% $30 copay; 40% $30 copay; 40% $60 copay; 10% 40% 20% $0 copay; $0 copay; $0 copay; 40% $0 copay; 40% $0 copay; 40% $0 copay; Inpatient Hospital 10% 40% 20% Outpatient Surgery (OP hospital department & freestanding facility) Emergency Services (Copay waived if admitted) Urgent Care Chiropractic (Limited to 26 visits per calendar year) Prescription Drugs 3 Retail: up to a 30-day supply Mail order: up to a 90-day supply; 2.5X retail copay Aetna Specialty Care Rx SM (Does not include insulin) 10% 40% 20% 10% after $250 copay; $75 copay; $25 copay; Paid as in network 20% after $250 copay; 40% $75 copay; 40% $30 copay; Paid as in network $10/$40/$65 $10/$40/$65 plus 30% $15/$50/$70 $15/$50/$70 plus 30% 25% copay, max copay $200 per 30 days 25% copay, max copay $200 per 30 days 90-Day Rx Transition of Coverage (TOC) Included Included for precertification 4 See page 22 for footnotes. 10

11 Aetna Managed Choice Open Access Plan Options MO/KS OAMC $ /50-12 MO/KS OAMC $ /50 SC-12 PCP/Referrals Required No N/A No N/A Member Benefits In network Out of network 1 In network Out of network 1 Member Coinsurance 20% 20% Professional Facility Calendar-Year Deductible (In-network and out-of-network expenses accumulate separately) $1,500 Individual $3,000 Family $3,000 Individual $6,000 Family $1,500 Individual $4,500 Family $3,000 Individual $9,000 Family Calendar-Year Out-of-Pocket Maximum (Includes deductible; Copayments and certain payments do not apply; Accumulates separately in network/out of network) $4,500 Individual $9,000 Family $8,000 Individual $16,000 Family $5,000 Individual $15,000 Family $8,000 Individual $24,000 Family Deductible and Out-of-Pocket Maximum Accumulation Embedded 2 Embedded 2 Lifetime Maximum Benefit Unlimited Unlimited Primary Physician Office Visit Specialist Office Visit Walk-In Clinics Outpatient Lab Outpatient X-ray Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET scan; precertification required) Physical Exams - Adults (Age and frequency schedules apply) Well-Child Exams (Age and frequency schedules apply) Routine GYN (Frequency schedules apply) $30 copay; $60 copay; $30 copay; $30 copay; $60 copay; $30 copay; $60 copay; $30 copay; $30 copay; $60 copay; 20% 20% $0 copay; $0 copay; $0 copay; $0 copay; $0 copay; $0 copay; Inpatient Hospital 20% 20% Professional Facility Outpatient Surgery (OP hospital department & freestanding facility) Emergency Services (Copay waived if admitted) Urgent Care Chiropractic (Limited to 26 visits per calendar year) Prescription Drugs 3 Retail: up to a 30-day supply Mail order: up to a 90-day supply; 2.5X retail copay Aetna Specialty Care Rx SM (Does not include insulin) 20% 20% Professional Facility 20% after $250 copay; $75 copay; $30 copay; Paid as in network 20% Professional, Facility after $250 copay; $75 copay; $30 copay; Paid as in network $15/$50/$70 $15/$50/$70 plus 30% $15/$50/$70 $15/$50/$70 plus 30% 25% copay, max copay $200 per 30 days 25% copay, max copay $200 per 30 days 90-Day Rx Transition of Coverage (TOC) Included Included for precertification 4 See page 22 for footnotes. 11

12 Aetna Managed Choice Open Access Plan Options MO/KS OAMC $2, %-12 MO/KS OAMC $ /50-12 PCP/Referrals Required No N/A No N/A Member Benefits In network Out of network 1 In network Out of network 1 Member Coinsurance 0% 30% 20% Calendar-Year Deductible (In-network and out-of-network expenses accumulate separately) $2,000 Individual $6,000 Family $6,000 Individual $18,000 Family $2,000 Individual $4,000 Family $4,000 Individual $8,000 Family Calendar-Year Out-of-Pocket Maximum (Includes deductible; Copayments and certain payments do not apply; Accumulates separately in network/out of network) $2,000 Individual $6,000 Family $9,000 Individual $27,000 Family $5,000 Individual $10,000 Family $8,000 Individual $16,000 Family Deductible and Out-of-Pocket Maximum Accumulation Embedded 2 Embedded 2 Lifetime Maximum Benefit Unlimited Unlimited Primary Physician Office Visit Specialist Office Visit Walk-In Clinics Outpatient Lab Outpatient X-ray Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET scan; precertification required) Physical Exams - Adults (Age and frequency schedules apply) Well-Child Exams (Age and frequency schedules apply) Routine GYN (Frequency schedules apply) $35 copay; $50 copay; $35 copay; $35 copay; $50 copay; 30% $35 copay; 30% $70 copay; 30% $35 copay; 30% $35 copay; 30% $70 copay; 0% 30% 20% $0 copay; $0 copay; $0 copay; 30% $0 copay; 30% $0 copay; 30% $0 copay; Inpatient Hospital 0% 30% 20% Outpatient Surgery (OP hospital department & freestanding facility) Emergency Services (Copay waived if admitted) Urgent Care Chiropractic (Limited to 26 visits per calendar year) Prescription Drugs 3 Retail: up to a 30-day supply Mail order: up to a 90-day supply; 2.5X retail copay Aetna Specialty Care Rx SM (Does not include insulin) 0% 30% 20% $300 copay; deductible waived $100 copay; Paid as in network 20% after $250 copay; 30% $100 copay; 0% 30% $35 copay; Paid as in network $15/$50/$70 $15/$50/$70 plus 30% $20/$40/$70 $20/$40/$70 plus 30% 25% copay, max copay $200 per 30 days 25% copay, max copay $200 per 30 days 90-Day Rx Transition of Coverage (TOC) Included Included for precertification 4 See page 22 for footnotes. 12

13 Aetna Managed Choice Open Access Plan Options MO/KS OAMC $ /50-12 MO/KS OAMC $3, %-12 PCP/Referrals Required No N/A No N/A Member Benefits In network Out of network 1 In network Out of network 1 Member Coinsurance 20% 0% 30% Calendar-Year Deductible (In-network and out-of-network expenses accumulate separately) $2,500 Individual $5,000 Family $5,000 Individual $10,000 Family $3,000 Individual $9,000 Family $6,000 Individual $18,000 Family Calendar-Year Out-of-Pocket Maximum (Includes deductible; Copayments and certain payments do not apply; Accumulates separately in network/out of network) $6,000 Individual $12,000 Family $9,000 Individual $18,000 Family $3,000 Individual $9,000 Family $9,000 Individual $27,000 Family Deductible and Out-of-Pocket Maximum Accumulation Embedded 2 Embedded 2 Lifetime Maximum Benefit Unlimited Unlimited Primary Physician Office Visit Specialist Office Visit Walk-In Clinics Outpatient Lab Outpatient X-ray Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET scan; precertification required) Physical Exams - Adults (Age and frequency schedules apply) Well-Child Exams (Age and frequency schedules apply) Routine GYN (Frequency schedules apply) $35 copay; $70 copay; $35 copay; $35 copay; $70 copay; $35 copay; $50 copay; $35 copay; $35 copay; $50 copay; 30% 30% 30% 30% 30% 20% 0% 30% $0 copay; $0 copay; $0 copay; $0 copay; $0 copay; $0 copay; Inpatient Hospital 20% 0% 30% Outpatient Surgery (OP hospital department & freestanding facility) Emergency Services (Copay waived if admitted) Urgent Care Chiropractic (Limited to 26 visits per calendar year) Prescription Drugs 3 Retail: up to a 30-day supply Mail order: up to a 90-day supply; 2.5X retail copay Aetna Specialty Care Rx SM (Does not include insulin) 30% 30% 30% 20% 0% 30% 20% after $250 copay; $100 copay; $35 copay; Paid as in network $300 copay; deductible waived $100 copay; Paid as in network 30% 0% 30% $20/$40/$70 $20/$40/$70 plus 30% $15/$50/$70 $15/$50/$70 plus 30% 25% copay, max copay $200 per 30 days 25% copay, max copay $200 per 30 days 90-Day Rx Transition of Coverage (TOC) Included Included for precertification 4 See page 22 for footnotes. 13

14 Aetna Managed Choice Open Access Plan Options MO/KS OAMC $ /50 SC-12 MO/KS OAMC $5, %-12 PCP/Referrals Required No N/A No N/A Member Benefits In network Out of network 1 In network Out of network 1 Member Coinsurance Calendar-Year Deductible (In-network and out-of-network expenses accumulate separately) Calendar-Year Out-of-Pocket Maximum (Includes deductible; Copayments and certain payments do not apply; Accumulates separately in network/out of network) 20% Professional Facility $3,000 Individual $9,000 Family $8,000 Individual $24,000 Family 0% 30% $5,000 Individual $15,000 Family $10,000 Individual $30,000 Family $5,000 Individual $15,000 Family $5,000 Individual $15,000 Family Deductible and Out-of-Pocket Maximum Accumulation Embedded 2 Embedded 2 Lifetime Maximum Benefit Unlimited Unlimited Primary Physician Office Visit Specialist Office Visit Walk-In Clinics Outpatient Lab Outpatient X-ray Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET scan; precertification required) Physical Exams - Adults (Age and frequency schedules apply) Well-Child Exams (Age and frequency schedules apply) Routine GYN (Frequency schedules apply) Inpatient Hospital Outpatient Surgery (OP hospital department & freestanding facility) Emergency Services (Copay waived if admitted) Urgent Care Chiropractic (Limited to 26 visits per calendar year) Prescription Drugs 3 Retail: up to a 30-day supply Mail order: up to a 90-day supply; 2.5X retail copay Aetna Specialty Care Rx SM (Does not include insulin) $30 copay; $60 copay; $30 copay; $30 copay; $60 copay; $35 copay; $50 copay; $35 copay; $35 copay; $50 copay; $68000 Individual $24,000 Family $10,000 Individual $30,000 Family 30% 30% 30% 30% 30% 20% 0% 30% $0 copay; $0 copay; $0 copay; 20% Professional Facility 20% Professional Facility 20% Professional, Facility after $250 copay; $75 copay; $30 copay; $0 copay; $0 copay; $0 copay; 30% 30% 30% 0% 30% 0% 30% Paid as in network $300 copay; $100 copay; Paid as in network 30% 0% 30% $15/$50/$70 $15/$50/$70 plus 30% $15/$50/$70 $15/$50/$70 plus 30% 25% copay, max copay $200 per 30 days 25% copay, max copay $200 per 30 days 90-Day Rx Transition of Coverage (TOC) Included Included for precertification 4 See page 22 for footnotes. 14

15 Aetna Managed Choice Open Access Plan Options MO/KS OAMC $5,000 70/50-12 PCP/Referrals Required No N/A Member Benefits In network Out of network 1 Member Coinsurance 30% Calendar-Year Deductible (In-network and out-of-network expenses accumulate separately) Calendar-Year Out-of-Pocket Maximum (Includes deductible; Copayments and certain payments do not apply; Accumulates separately in network/out of network) $5,000 Individual $10,000 Family $9,000 Individual $18,000 Family $8,000 Individual $16,000 Family $13,000 Individual $26,000 Family Deductible and Out-of-Pocket Maximum Accumulation Embedded 2 Lifetime Maximum Benefit Primary Physician Office Visit Specialist Office Visit Walk-In Clinics Outpatient Lab Outpatient X-ray Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET scan; precertification required) Physical Exams - Adults (Age and frequency schedules apply) Well-Child Exams (Age and frequency schedules apply) Routine GYN (Frequency schedules apply) $35 copay; $70 copay; $35 copay; $35 copay; $70 copay; Unlimited 30% $0 copay; $0 copay; $0 copay; Inpatient Hospital 30% Outpatient Surgery (OP hospital department & freestanding facility) Emergency Services (Copay waived if admitted) Urgent Care Chiropractic (Limited to 26 visits per calendar year) Prescription Drugs 3 Retail: up to a 30-day supply Mail order: up to a 90-day supply; 2.5X retail copay Aetna Specialty Care Rx SM (Does not include insulin) 90-Day Rx Transition of Coverage (TOC) for precertification 4 30% 30% after $250 copay; $100 copay; $35 copay; Paid as in network $20/$40/$70 $20/$40/$70 plus 30% 25% copay, max copay $200 per 30 days Included See page 22 for footnotes. 15

16 Aetna Managed Choice Open Access Plan Options (Available to groups with employees only) MO/KS OAMC $2500 (EMB) 100% HSA-12 MO/KS OAMC $3,500 (EMB) 100% HSA-12 PCP/Referrals Required No N/A No N/A Member Benefits In network Out of network 1 In network Out of network 1 Member Coinsurance 0% 30% 0% 30% Calendar-Year Deductible (In-network and out-of-network expenses accumulate separately) $2,500 Individual $5,000 Family $5,000 Individual $10,000 Family $3,500 Individual $7,000 Family $7,000 Individual $14,000 Family Calendar-Year Out-of-Pocket Maximum (Includes deductible and Copayments for prescription drugs; Accumulates separately in network/out of network) $3,500 Individual $7,000 Family $10,000 Individual $20,000 Family $4,500 Individual $9,000 Family $12,000 Individual $24,000 Family Deductible and Out-of-Pocket Maximum Accumulation Embedded 2 Embedded 2 Lifetime Maximum Benefit Unlimited Unlimited Primary Physician Office Visit 0% 30% 0% 30% Specialist Office Visit 0% 30% 0% 30% Walk-In Clinics 0% 30% 0% 30% Outpatient Lab 0% 30% 0% 30% Outpatient X-ray 0% 30% 0% 30% Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET scan; precertification required) 0% 30% 0% 30% Physical Exams - Adults (Age and frequency schedules apply) Well-Child Exams (Age and frequency schedules apply) Routine GYN (Frequency schedules apply) $0 copay; $0 copay; $0 copay; 30% $0 copay; 30% $0 copay; 30% $0 copay; Inpatient Hospital 0% 30% 0% 30% Outpatient Surgery (OP hospital department & freestanding facility) Emergency Services (Copay waived if admitted) 30% 30% 30% 0% 30% 0% 30% 0% Paid as in network 0% Paid as in network Urgent Care 0% 30% 0% 30% Chiropractic (Limited to 26 visits per calendar year) Prescription Drugs 3 Retail: up to a 30-day supply Mail order: up to a 90-day supply; 2.5X retail copay Aetna Specialty Care Rx SM (Does not include insulin) 0% 30% 0% 30% $10/$40/$65 after deductible 25% copay, max copay $200 per 30 days; after deductible $10/$40/$65 plus 30% after deductible $10/$40/$65 after deductible 25% copay, max copay $200 per 30 days; after deductible 90-Day Rx Transition of Coverage (TOC) Included Included for precertification 4 $10/$40/$65 plus 30% after deductible See page 22 for footnotes. 16

17 Aetna Managed Choice Open Access Plan Options MO/KS OAMC $3,500 (EMB) 90/60 HSA-12 MO/KS OAMC $5,000 (EMB) 90/60 HSA-12 PCP/Referrals Required No N/A No N/A Member Benefits In network Out of network 1 In network Out of network 1 Member Coinsurance 10% 40% 10% 40% Calendar-Year Deductible (In-network and out-of-network expenses accumulate separately) $3,500 Individual $7,000 Family $7,000 Individual $14,000 Family $5,000 Individual $10,000 Family $8,000 Individual $16,000 Family Calendar-Year Out-of-Pocket Maximum (Includes deductible and Copayments for prescription drugs; Accumulates separately in network/out of network) $6,050 Individual $12,100 Family $12,000 Individual $24,000 Family $6,050 Individual $12,100 Family $14,000 Individual $28,000 Family Deductible and Out-of-Pocket Maximum Accumulation Embedded 2 Embedded 2 Lifetime Maximum Benefit Unlimited Unlimited Primary Physician Office Visit 10% 40% 10% 40% Specialist Office Visit 10% 40% 10% 40% Walk-In Clinics 10% 40% 10% 40% Outpatient Lab 10% 40% 10% 40% Outpatient X-ray 10% 40% 10% 40% Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET scan; precertification required) 10% 40% 10% 40% Physical Exams - Adults (Age and frequency schedules apply) Well-Child Exams (Age and frequency schedules apply) Routine GYN (Frequency schedules apply) $0 copay; $0 copay; $0 copay; 40% $0 copay; 40% $0 copay; 40% $0 copay; Inpatient Hospital 10% 40% 10% 40% Outpatient Surgery (OP hospital department & freestanding facility) Emergency Services (Copay waived if admitted) 40% 40% 40% 10% 40% 10% 40% 10% Paid as in network 10% Paid as in network Urgent Care 10% 40% 10% 40% Chiropractic (Limited to 26 visits per calendar year) Prescription Drugs 3 Retail: up to a 30-day supply Mail order: up to a 90-day supply; 2.5X retail copay Aetna Specialty Care Rx SM (Does not include insulin) 10% 40% 10% 40% $10/$40/$65 after deductible 25% copay, max copay $200 per 30 days; after deductible $10/$40/$65 plus 30% after deductible $10/$40/$65 after deductible 25% copay, max copay $200 per 30 days; after deductible 90-Day Rx Transition of Coverage (TOC) Included Included for precertification 4 $10/$40/$65 plus 30% after deductible See page 22 for footnotes. 17

18 Aetna Managed Choice Open Access Plan Options MO/KS OAMC $2,000 90/60 HRA/HYB (EMB)-12 PCP/Referrals Required No N/A Member Benefits In network Out of network 1 Member Coinsurance 10% 40% Calendar-Year Deductible (In-network and out-of-network expenses accumulate separately) $2,000 Individual $4,000 Family $6,000 Individual $12,000 Family Calendar-Year Out-of-Pocket Maximum (Includes deductible and Copayments for prescription drugs; Accumulates separately in network/out of network) $5,000 Individual $10,000 Family $12,000 Individual $24,000 Family Deductible and Out-of-Pocket Maximum Accumulation Embedded 2 Lifetime Maximum Benefit Unlimited Primary Physician Office Visit 10% 40% Specialist Office Visit 10% 40% Walk-In Clinics 10% 40% Outpatient Lab 10% 40% Outpatient X-ray 10% 40% Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET scan; precertification required) Physical Exams - Adults (Age and frequency schedules apply) Well-Child Exams (Age and frequency schedules apply) Routine GYN (Frequency schedules apply) 10% 40% $0 copay; $0 copay; $0 copay; 40% 40% 40% Inpatient Hospital 10% 40% Outpatient Surgery (OP hospital department & freestanding facility) Emergency Services (Copay waived if admitted) 10% 40% 10% Paid as in network Urgent Care 10% 40% Chiropractic (Limited to 26 visits per calendar year) Prescription Drugs 3 Retail: up to a 30-day supply Mail order: up to a 90-day supply; 2.5X retail copay Aetna Specialty Care Rx SM (Does not include insulin) 90-Day Rx Transition of Coverage (TOC) for precertification 4 10% 40% $10/$40/$65 $10/$40/$65 plus 30% 25% copay, max copay $200 per 30 days Included See page 22 for footnotes. 18

19 Aetna Open Choice PPO and Indemnity Plan Options MO/KS PPO $ /50-12 MO/KS PPO $3, %-12 PCP/Referrals Required No N/A No N/A Member Benefits In network Out of network 1 In network Out of network 1 Member Coinsurance 20% 0% 30% Calendar-Year Deductible (In-network and out-of-network expenses accumulate separately) $1,500 Individual $3,000 Family $3,000 Individual $6,000 Family $3,000 Individual $9,000 Family $6,000 Individual $18,000 Family Calendar-Year Out-of-Pocket Maximum (Includes deductible; Copayments and certain payments do not apply; Accumulates separately in network/out of network) $4,500 Individual $9,000 Family $8,000 Individual $16,000 Family $3,000 Individual $9,000 Family $9,000 Individual $27,000 Family Deductible and Out-of-Pocket Maximum Accumulation Embedded 2 Embedded 2 Lifetime Maximum Benefit Unlimited Unlimited Primary Physician Office Visit Specialist Office Visit Walk-In Clinics Outpatient Lab Outpatient X-ray Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET scan; precertification required) Physical Exams - Adults (Age and frequency schedules apply) Well-Child Exams (Age and frequency schedules apply) Routine GYN (Frequency schedules apply) $30 copay; $60 copay; $30 copay; $30 copay; $60 copay; $35 copay; $50 copay; $35 copay; $35 copay; $50 copay; 30% 30% 30% 30% 30% 20% 0% 30% $0 copay; $0 copay; $0 copay; $0 copay; $0 copay; $0 copay; Inpatient Hospital 20% 0% 30% Outpatient Surgery (OP hospital department & freestanding facility) Emergency Services (Copay waived if admitted) Urgent Care Chiropractic (Limited to 26 visits per calendar year) Prescription Drugs 3 Retail: up to a 30-day supply Mail order: up to a 90-day supply; 2.5X retail copay Aetna Specialty Care Rx SM (Does not include insulin) 30% 30% 30% 20% 0% 30% 20% after $250 copay; $75 copay; $30 copay; Paid as in network $300 copay; $100 copay; Paid as in network 30% 0% 30% $15/$50/$70 $15/$50/$70 plus 30% $15/$50/$70 $15/$50/$70 plus 30% 25% copay, max copay $200 per 30 days 25% copay, max copay $200 per 30 days 90-Day Rx Transition of Coverage (TOC) Included Included for precertification 4 See page 22 for footnotes. 19

20 Aetna Indemnity Plan Options PCP/Referrals Required MO/KS Indemnity-12 N/A Member Benefits Out of network 1 Member Coinsurance 20% Calendar-Year Deductible Calendar-Year Out-of-Pocket Maximum (Includes deductible; Copayments and certain payments do not apply) $1,000 Individual $3,000 Family $4,000 Individual $12,000 Family Deductible and Out-of-Pocket Maximum Accumulation Embedded 2 Lifetime Maximum Benefit Primary Physician Office Visit 20% Specialist Office Visit 20% Walk-In Clinics 20% Outpatient Lab 20% Outpatient X-ray 20% Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET scan; precertification required) Physical Exams - Adults (Age and frequency schedules apply) Well-Child Exams (Age and frequency schedules apply) Routine GYN (Frequency schedules apply) Unlimited 20% 20% 20% 20% Inpatient Hospital 20% Outpatient Surgery (OP hospital department & freestanding facility) Emergency Services (Copay waived if admitted) 20% 20% Urgent Care 20% Chiropractic (Limited to 26 visits per calendar year) Prescription Drugs 3 Retail: up to a 30-day supply Mail order: up to a 90-day supply; 2.5X retail copay Aetna Specialty Care Rx SM (Does not include insulin) 90-Day Rx Transition of Coverage (TOC) for precertification 4 20% $10/$40/$65 plus 30% 25% copay, max copay $200 per 30 days Included See page 22 for footnotes. 20

21 Aetna Health Network Only Plan Options PCP/Referrals Required Member Benefits Member Coinsurance 20% Calendar-Year Deductible Calendar-Year Out-of-Pocket Maximum (Includes copays) MO/KS Health Network Only $20-12 No In network None $3,000 Individual $6,000 Family Deductible and Out-of-Pocket Maximum Accumulation Embedded 2 Lifetime Maximum Benefit Primary Physician Office Visit Specialist Office Visit Walk-In Clinics Outpatient Lab Outpatient X-Ray Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET Scan; precertification required) Physical Exams - Adults (Age and frequency schedules apply) Well-Child Exams (Age and frequency schedules apply) Routine GYN (Frequency schedules apply) Inpatient Hospital Outpatient Surgery (OP hospital department & freestanding facility) Emergency Services (Copay waived if admitted) Urgent Care Chiropractic (Limited to 26 visits per calendar year) Prescription Drugs Retail: up to a 30-day supply Mail order: up to a 90-day supply; 2.5X retail copay Aetna Specialty Care Rx SM (Does not include insulin) 90-Day Rx Transition of Coverage (TOC) for precertification 4 Unlimited $20 copay $50 copay $20 copay $20 copay $50 copay $250 copay $0 copay $0 copay $0 copay $300 copay per day; max $1,500 per admit $250 copay 20% after $150 copay; $75 copay; $20 copay $10/$35/$60 25% copay, max copay $200 per 30 days Included See page 22 for footnotes. 21

22 Footnotes The dollar and percentage coinsurance amounts indicate what the member is required to pay. Some benefits are subject to limitations or visit maximums. Members or providers may be required to precertify for certain services such as outpatient complex imaging and non-emergency hospital care. All services are subject to deductible, unless noted otherwise. Amounts over allowable charges, failure-to-precertify penalty, copays (including copayments and coinsurance for prescription drugs) and DME do not apply toward the out-of-pocket maximums and continue to be payable after the maximum is reached. Note: On the HSA-compatible plans, only amounts over allowable charges and failure-to-precertify penalty do not apply toward the out-of-pocket maximum and continue to be payable after the maximum is reached. For a summary list of Limitations and Exclusions, refer to page We cover the cost of services based on whether doctors are in network or out of network. We want to help you understand how much Aetna pays for your out-of-network care. At the same time, we want to make it clear how much more you will need to pay for this out-of-network care. You may choose a provider (doctor or hospital) in our network. You have 2 levels of in-network care, Level 1 includes designated providers for maximum savings and Level 2 includes nondesignated providers for standard savings. You may choose to visit an out-of-network provider. If you choose a doctor who is out of network, your Aetna health plan may pay some of that doctor s bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital. When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the recognized or allowed amount. When you choose out-of-network care, Aetna recognizes an amount based on what Medicare pays for these services. The government sets the Medicare rate. Your doctor sets his or her own rate to charge you. It may be higher sometimes much higher than what your Aetna plan recognizes. Your doctor may bill you for the dollar amount that Aetna doesn t recognize. You must also pay any copayments, coinsurance and deductibles under your plan. No dollar amount above the recognized charge counts toward your deductible or out-of-pocket maximums. To learn more about how we pay out-of-network benefits visit Type how Aetna pays in the search box. You can avoid these extra costs by getting your care from Aetna s broad network of health care providers. Go to and click on Find a Doctor on the left side of the page. If you are already a member, sign on to your Aetna Navigator member site. This applies when you choose to get care out of network. When you have no choice (for example: emergency room visit after a car accident, or for other emergency services), we will pay the bill as if you got care in network. You pay cost sharing and deductibles for your in-network level of benefits. Contact Aetna if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your cost sharing and deductibles. 22

23 2 Each covered family member only needs to satisfy his or her individual deductible, not the entire family deductible. 3 The four Rx Tiers are Tier 1: Generic Formulary, Tier 2: Brand Formulary, Tier 3: Brand Nonformulary, Tier 4: Specialty Care Rx. 4 Transition of Coverage (TOC) applies to precertification for prescription drugs. It helps members of newly enrolled groups to transition to the Aetna drug formulary by providing a 90-calendar day opportunity, beginning on the group s initial effective date, during which time precertification will not apply to certain drugs as listed in the formulary guide. Once the 90 calendar days has expired, precertification will apply to all drugs requiring precertification as listed in the formulary guide. Members who have claims paid for a drug requiring precertification during the TOC period may continue to receive this drug after the 90 calendar days and will not be required to obtain a precertification approval for a medical exception to this drug. Women s Preventive Health Benefits New changes effective August 1, 2012 As you may know, the Affordable Care Act (ACA, or Health Care Reform law) includes changes that are being phased in over a number of years. The latest set of changes includes additional benefits for certain Women s Preventive Health Services. When plans renew or are effective on or after August 1, 2012, all of the following women s health services will be considered preventive (some were already covered). These services generally will be covered at no cost share, when provided in network: Well-woman visits (annually and now including prenatal visits) Screening for gestational diabetes Human papillomavirus (HPV) DNA testing Counseling for sexually transmitted infections Counseling and screening for human immunodeficiency virus (HIV) Screening and counseling for interpersonal and domestic violence Breastfeeding support, supplies and counseling Generic formulary contraceptives, certain brand formulary contraceptives, and FDA-approved over-the-counter female contraceptives with prescription are covered without member cost share (for example, no copayment); certain religious organizations or religious employers may be exempt from offering contraceptive services 23

24 Aetna Dental Plans Small business decision makers can choose from a variety of plan design options that help you offer a dental benefits and dental insurance plan that s just right for your employees. 24

25 Dental Overview The Mouth Matters SM Research suggests that serious gum disease, known as periodontitis, may be associated with many health problems. This is especially true if serious gum disease continues without treatment. 1,2 Now, here s the good news. Researchers are discovering that a healthy mouth may be important to your overall health. 1,2 The Aetna Dental/Medical Integration SM (DMI) program,* available at no additional charge to plan sponsors that have both medical and dental coverages with Aetna, focuses on those who are pregnant or have diabetes, coronary artery disease (heart disease) or cerebrovascular disease (stroke) and have not had a recent dental visit. We proactively educate those at-risk members about the impact oral health care can have on their condition. Our member outreach has been proven to successfully motivate those at-risk members who do not normally seek dental care. Once at the dentist s, these at-risk members will receive enhanced dental benefits, including an extra cleaning and full coverage for certain periodontal services. The Dental Maintenance Organization (DMO ) Members select a primary care dentist to coordinate their care from the available managed dental network. Each family member may choose a different primary care dentist and may switch dentists at any time via Aetna Navigator or with a call to Member Services. If specialty care is needed, a member s primary care dentist can refer the member to a participating specialist. However, members may visit orthodontists without a referral. There are virtually no claim forms to file, and benefits are not subject to deductibles or annual maximums. Preferred Provider Organization (PPO) plan Members can choose a dentist who participates in the network or choose a licensed dentist who does not. Participating dentists have agreed to offer our members covered services at a negotiated rate. PPO Max plan While the PPO Max dental insurance plan uses the PPO network, when members use out-of-network dentists, the service will be covered based on the Aetna PPO fee schedule rather than on the reasonable and customary charge. The member will share in more of the costs and may be balance-billed. This plan offers members a quality dental insurance plan with a significantly lower premium that encourages in-network usage. Freedom-of-Choice plan design option Get maximum flexibility with our two-in-one dental plan design. The Freedom-of-Choice plan design option provides the administrative ease of one plan, yet members get to choose between the DMO and PPO plans on a monthly basis. One blended rate is paid. Members may switch between the plans on a monthly basis by calling Member Services. Plan changes must be made by the 15 th of the month to be effective the following month. Aetna Dental Preventive Care SM plan The preventive care plan is a low cost dental plan that covers preventive and diagnostic procedures. Members pay nothing for these services when visiting an in-network dentist. Dual option** plan In the dual option plan design, the DMO may be packaged with any one of the PPO plans. Employees may choose between the DMO and PPO offerings at annual enrollment. Voluntary dental option The voluntary dental option provides a solution to meet the individual needs of members in the face of rising health care costs. Administration is easy, and members benefit from low group rates and the convenience of payroll deductions. *DMI may not be available in all states. **Dual option does not apply to preventive-only plans and 3-9 Voluntary groups. 1 MayoClinic.com. Oral health: A window to your overall health. Available online at Accessed May R.C. Williams, A.H. Barnett, N. Claffey, M. Davis, R. Gadsby, M. Kellett, G.Y.H. Lip, and S. Thackray. The potential impact of periodontal disease on general health: a consensus view. Current Medical Research and Opinion, Vol. 24, No. 6, 2008,