2013 Health Benefits Guide for HRA-Eligible Employees

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1 2013 Health Benefits Guide for HRA-Eligible Employees Revised: August 2013

2 Health Benefits Guide for HRA-Eligible Employees Table of Contents Important Phone Numbers... 5 Introduction... 6 Eligibility... 6 Health Reimbursement Arrangement (or HRA)... 7 A Quick Look... 7 How the Health Reimbursement Arrangement Works... 7 Eligible Health Reimbursement Arrangement Expenses... 7 Filing Health Reimbursement Arrangement (HRA) Claims... 7 Deadline for Submitting Claims... 8 Receiving Reimbursement... 8 Claim Determinations... 8 If You Terminate Employment with TI... 9 For Additional Information on Health Reimbursement Arrangements... 9 Health and Wellness A Quick Look Pre-January 1, 2012 Hires Post-December 31, 2011 Hires Aetna HealthFund (HRA) Medical - Aetna HealthFund (HRA) Deductibles and Coinsurance Networks Network Provider Verification - Network providers/locations are subject to change without notice Network/Non-Network Pre-Certification Precertification Process Your Benefits What is Covered under the Aetna HealthFund (HRA) Option Covered Amounts Network Doctor Case Management Recognized Charge Additional Information What You Will Pay Expenses that are Not Covered Pre-Existing Conditions Certificate of Group Health Plan Coverage Deductibles and Coinsurances in the Aetna HealthFund (HRA) Lifetime Limits Adult Preventive Health Care Routine Physical Exams Preventive Care Immunizations Flu Vaccinations Well Woman Preventive Visits Routine Cancer Screenings Prenatal Care Comprehensive Lactation Support and Counseling Services Breast Feeding Durable Medical Equipment Family Planning Services Voluntary Sterilization Contraceptives Preventive Health Care for Infants and Children (0 Months-18 Years) Contents

3 Immunizations and Lab Tests Infant and Child Check-ups Maximum Exams Screening and Counseling Services for Obesity, Misuse of Alcohol and/or Drugs, Use of Tobacco Products Obesity Misuse of Alcohol and/or Drugs Use of Tobacco Products Inpatient Maternity Admissions Urgent Care Emergency Care Other Covered Expenses Bariatric Treatment Expenses Morbid Obesity Surgical Expenses Prosthetic Devices Behavioral Health Care What Happens When You Call the EAP? Treatment of Mental Disorders and Substance Abuse Inpatient Treatment for Mental Disorders Inpatient Treatment for Substance Abuse Partial Confinement Treatment Outpatient Treatment Additional Behavioral Counseling Benefits Behavioral Health Care Services Not Covered under the Aetna HealthFund (HRA) Option Second Surgical Opinion (Optional) How a Second Opinion is Handled Other Covered Expenses Allergy Testing and Treatment Chiropractic Services Durable Medical Equipment Home Health Care Hospice Care Program Jaw Joint Disorder Treatment Oral and Maxillofacial Treatment (Mouth, Jaws and Teeth) Dietitian Consultations Outpatient Physical and Occupational Therapy Benefits Treatment for Loss or Impairment of Speech Skilled Nursing Facility Human Organ or Tissue Transplants Know Your Benefits Claiming Medical Benefits When You Must File Your Claims Payment of Hospital Expenses Payment of Doctor Expenses Health Reimbursement Arrangement Medical Benefit Exclusions and Limitations Services that are Not Covered under the Aetna HealthFund (HRA) Option Right to Rescind Coverage Aetna HealthFund (HRA) Option Pharmacy Network Prescription Benefits Aetna HealthFund (HRA) Option Quality Care Lost or Stolen Medication Covered Drugs Subject to Prior Authorization Covered Drugs Subject to Dispensing Limitations Contents 3

4 Claiming Benefits When You Must File Your Pharmacy Claims Health Reimbursement Arrangement Pharmacy Benefit Exclusions and Limitations Subrogation and Right of Recovery Provision Definitions Subrogation Reimbursement Constructive Trust Lien Rights First-Priority Claim Applicability to All Settlements and Judgments Cooperation Interpretation Jurisdiction Claims, Appeals and External Review If You Need Help Filing a Claim Filing Health Claims under the Aetna HealthFund (HRA) Option Urgent Care Claims Other Claims (Pre-Service and Post-Service) Ongoing Course of Treatment Health Claims Standard Appeals Exhaustion of Internal Appeals Process Full and Fair Review of Claim Determinations and Appeals External Review Request for External Review Preliminary Review Referral to ERO Expedited External Review Referral of Expedited Review to ERO Important Health Care Reform Notice Choice of Provider Contents

5 Important Phone Numbers TI HR Connect - One number to access benefit providers and obtain guidance Aetna HealthFund (HRA) o Medical Aetna Choice POS II o Pharmacy - Aetna Pharmacy Management Employee Assistance Program (EAP) (Magellan Health) Aetna Life Insurance Company Important Phone Numbers 5

6 Introduction This guide describes the Aetna HealthFund (HRA) option with a Health Reimbursement Arrangement, and is a special supplement to the Summary Plan Description of Texas Instruments Incorporated s (TI s) health and welfare benefit plans and programs, known as the Texas Instruments 2013 Health and Insurance Benefits Guide. The Aetna HealthFund (HRA) option with a Health Reimbursement Arrangement is available to participants who were eligible for coverage under a National Semiconductor Corporation (NSC) sponsored medical benefit on December 31, This option may not be offered beyond Any amounts remaining in a Health Reimbursement Arrangement when such option is discontinued will be forfeited. The option described in this guide is governed by the Employee Retirement Income Security Act of 1974 (ERISA). For further information on other benefits and enrollment rules see the Texas Instruments 2013 Health and Insurance Benefits Guide. The summary description is written in plain language to help you understand how this option works. If there is a conflict between the information in this guide and the plan document and/or contracts, the plan document and/or contracts will govern. Eligibility You are only eligible for coverage under the Aetna HealthFund (HRA) option described in this supplement if you were eligible for coverage under a NSC sponsored medical benefit on December 31, 2011, you elected Aetna HealthFund (HRA) coverage for 2012 and are a full-time TIer or part-time TIer on an alternative work schedule (minimum 20-hours-a-week schedule). 6 Health Reimbursement Arrangement

7 Health Reimbursement Arrangement (or HRA) (Note: The Health Reimbursement Arrangement applies to COBRA participants) ERISA PLAN, offered through the Texas Instruments Incorporated Flexible Benefits Plan A Quick Look If you have a Health Reimbursement Arrangement (or HRA), you have a tax-advantaged benefit previously funded by National Semiconductor Corporation (NSC) which is part of the Aetna Choice POS II Medical Plan. Expenses that may be reimbursed from the HRA include: deductibles, co-insurance, out-ofpocket maximums, prescription medications, and other eligible out-of-pocket health-related expenses. Any unused amounts in the HRA can be carried forward for reimbursements in later years provided the Aetna HealthFund (HRA) option remains available. How the Health Reimbursement Arrangement Works If you elect to enroll in the Aetna HeathFund (HRA) option, you will begin 2013 with the amount of funds in your Health Reimbursement Arrangement as of December 31, You may not contribute, nor will TI contribute, any amount to the Health Reimbursement Arrangement. Funds in the Health Reimbursement Arrangement may only be used to reimburse health care expenses you and your Dependents incur during the plan year. You may not transfer any funds between the Health Care Spending Account, Dependent Daycare Spending Account, Dental and Vision Spending Account, Health Savings Account or the Health Reimbursement Arrangement. For more information on the Health Care Spending Account, Dependent Day Care Spending Account, Dental and Vision Spending Account, and Health Savings Account, see the 2013 Texas Instruments Health and Insurance Benefits Guide. Eligible Health Reimbursement Arrangement Expenses The Aetna HealthFund (HRA) option covers the same expenses as those covered under the Aetna Choice POS II Medical Plan. These expenses must be incurred for medical care as defined in IRS Code Section 213(d). Expenses above the Recognized Charge, any Aetna HealthFund (HRA) option limits, and any non-covered expenses are not eligible for reimbursement under the Aetna HealthFund (HRA). Filing Health Reimbursement Arrangement (HRA) Claims If you are enrolled in the Aetna HealthFund (HRA) option, your out-of-pocket costs for medical and pharmacy expenses are automatically paid out of the balance in your Health Reimbursement Arrangement (HRA), if any. The network provider files the claim with Aetna, and Aetna pays your share of the cost out of your HRA. If you receive treatment from an out-of-network provider, you may have to file a claim. You can obtain a claim form on the Fidelity NetBenefits Web site. From the "Home Page" tab, select the "Health & Insurance" tab. You can click on Health and Insurance Overview link and select "All Health & Insurance Forms" at the bottom of the benefit summary. You can also obtain a claim form online at benefits.ti.com (click the Health tab and select Forms) or by contacting Aetna directly at or from the forms library on the Aetna Navigator website at Claims should be sent to: Aetna P.O. Box Lexington, KY You ll need to include itemized receipts or other supporting documentation. Please refer to the applicable Aetna claim form for information regarding the details required on receipts and other forms of supporting documentation that may be required. If you've lost your receipt, contact the provider to request a copy. Health Reimbursement Arrangement 7

8 Once your claim has been processed, you ll receive notification from Aetna regarding the status of your claim. Deadline for Submitting Claims All claims must be mailed and postmarked or faxed to Aetna no later than twelve months after the date on which the service or supply was provided; claims submitted after this deadline will be denied as untimely. Receiving Reimbursement If you elect coverage under the Health Care Spending Account and the Health Reimbursement Arrangement, you must first exhaust funds in the Health Reimbursement Arrangement before you can use any funds in the Health Care Spending Account. If any eligible expense is still outstanding after the Health Reimbursement Arrangement is exhausted, such expense must be submitted to Ceridian, the Claims Administrator for the Flexible Benefit Plan, at the time and in the manner prescribed by the Claims Administrator. If you elect coverage under the Health Reimbursement Arrangement, you may not contribute to the Health Savings Account or Dental and Vision Spending Account. Expenses incurred prior to the effective date of your enrollment in the Aetna HealthFund (HRA) are not eligible for reimbursement. Expenses will be reimbursed for the calendar year in which you receive the health care, not in the calendar year when you are billed, charged for or pay for the health care expense. Health Reimbursement Arrangement claims will be reimbursed up to the amount of your account. Any reimbursement for eligible expenses is not taxable. Claim Determinations If Aetna determines that you are not entitled to receive all or part of the benefits you claim in a postservice claim for benefits (other than a claim involving concurrent care), a notice will be provided to you within a reasonable period of time, but no later than 30 days from the day your claim was received by Aetna. This notice (which will be provided to you in writing by mail, or hand delivery, or through ) will describe (i) the Claims Administrator's determination, (ii) the basis for the determination (along with appropriate references to pertinent Flexible Benefits Plan provisions regarding the Health Reimbursement Arrangement on which the denial is based), and (iii) the procedure you must follow to obtain a review of the determination, including a description of the appeals procedure, and (iv) your right to bring a cause of action for benefits under section 502(a) of ERISA. This notice will also explain, if appropriate, how you may properly complete your claim and why the submission of additional information may be necessary. In certain instances, Aetna may not be able to make a determination within 30 days from the day your claim for benefits was submitted. In such situations, Aetna, in its sole and absolute discretion, may extend the 30-day period for up to 15 days, as long as the Claims Administrator determines that the extension is necessary due to matters beyond the control of the Claims Administrator and provides you with a written notice within the initial 30-day period that explains (i) the reason for the extension, and (ii) the date on which a decision is expected. If the reason for the delay is due to your failure to provide information necessary to decide your claim, the above-mentioned notice will describe the information needed and afford you 45 days from the day you receive the notice to provide the required information. However, a delay brought about by your failure to provide information necessary to decide your claim may result in a delay of the determination by Aetna. 8 Health Reimbursement Arrangement

9 If You Terminate Employment with TI Only the expenses you incurred while working as a TIer are eligible for reimbursement, unless you elect COBRA following termination. If your employment with TI terminates while you are participating in the Aetna HeathFund (HRA) and you have a Health Reimbursement Arrangement balance, you may continue to claim reimbursement for eligible expenses incurred after your termination date by electing COBRA coverage (See COBRA section) for the remainder of the plan year. If you do not elect COBRA coverage, you may only claim reimbursement for eligible expenses incurred prior to your termination date. Important Note: 1. You cannot be reimbursed for an eligible expense under this option and deduct the same expense on your federal income tax return. 2. You cannot be reimbursed for any medical or dental expenses from your Health Reimbursement Arrangement if the expense has been or will be paid by you, your spouse or domestic partner s insurance plan(s). For Additional Information on Health Reimbursement Arrangements You can visit the Aetna Navigator Web site at A link to the site is also available from the Fidelity NetBenefits Web site or by logging on to netbenefits.ti.com (click the Health tab and select Health Plans). Additionally, you can contact Aetna, the Health Reimbursement Arrangement Claims Administrator through TI HR Connect at Health Reimbursement Arrangement 9

10 Health and Wellness Medical Aetna HealthFund (HRA) Option with Health Reimbursement Arrangement ERISA PLAN, offered through the TI Employees Health Benefit Plan A Quick Look Pre-January 1, 2012 Hires If you were hired prior to Jan. 1, 2012, you may make an election to enroll in the Aetna HealthFund (HRA) option, the Blue Cross Blue Shield HDHP option, the Blue Cross Blue Shield PPO option, the CIGNA Copay option or a regional HMO. If you cease employment with TI for thirty days or more or elect coverage other than the Aetna HealthFund (HRA), you cease to be eligible to participate in the Aetna HealthFund (HRA). Post-December 31, 2011 Hires If you are hired on or after January 1, 2012, you may only make an election to enroll in the Blue Cross Blue Shield HDHP option. Aetna HealthFund (HRA) Key features of the Aetna HealthFund (HRA) option with the Health Reimbursement Arrangement are highlighted below. You will find more detailed information on the following pages. The Aetna HealthFund (HRA) option is the only enrollment option for TIers hired from NSC who had a Health Reimbursement Arrangement that will permit them to retain their Health Reimbursement Arrangement in Family deductible applies to you + spouse or domestic partner, you + child(ren) and you + family coverage and is met when all medical and pharmacy claims add up to the family deductible amount. No first-dollar coverage - the deductible must apply to all medical expenses (including prescriptions) covered under the Aetna HealthFund (HRA) option. Preventive care is the only exception. Only one out-of-pocket maximum applies to medical and pharmacy expenses. You may not contribute to a Health Savings Account if you enroll in the Aetna HealthFund (HRA) option. Any amount remaining in your Health Reimbursement Arrangement at December 31, 2012 will carry over and be available to you in later years provided the Aetna HealthFund (HRA) option remains available. Any qualified medical expense may be reimbursed under the Health Reimbursement Arrangement. If you contribute amounts to a Health Care Spending Account, you must use all of the funds available under the Health Reimbursement Arrangement before you can receive any reimbursement from your Health Care Spending Account. 10 Health and Wellness

11 Medical - Aetna HealthFund (HRA) Deductibles and Coinsurance A deductible is the amount you must pay for eligible expenses each year before most benefits begin. Coinsurance is the percentage that TI contributes to your eligible medical expenses after you meet your deductible (unless otherwise noted). Any costs not covered by the coinsurance is your responsibility, and you must pay this amount. Coinsurance amounts will depend on how, where and the kind of treatment provided. For an explanation of out-of-pocket expenses for medical or surgical treatment and for out-ofpocket expenses for behavioral health care treatment, call Aetna through TI HR Connect at Your out-of-pocket expenses will be less if you use network providers. The out-of-pocket maximum is the annual limit you will pay for most eligible expenses after the deductible is met. Some additional expenses are not applied toward the out-of-pocket maximum. Aetna HealthFund (HRA) Deductible and out-of-pocket accumulation Application of deductible to out-of-pocket maximum Pharmacy expenses applied to deductible Pharmacy expenses applied to out-of-pocket maximum You Only coverage accumulates to individual deductible and individual out-of-pocket maximum. You + Spouse or Domestic Partner, You + Child(ren) and You + Family coverages accumulate to Family Deductible and Family Out-of-Pocket Maximum. Deductibles apply to the out-of-pocket maximum. Applied to combined medical/behavioral health/pharmacy deductible. Applied to combined medical/behavioral health/pharmacy out-of-pocket maximum. Networks Aetna network providers offer care to TIers and covered family members at negotiated rates. Participating providers have agreed to a negotiated rate, which results in lower fees. By having negotiated rates, you and TI pay less for health care. Network Provider Verification - Network providers/locations are subject to change without notice. There are several ways to access or verify network health care providers: View the listing of network providers (including doctors, hospitals, and pharmacies) which can be found on the Fidelity NetBenefits Web site. From the Home Page tab, select the Health & Insurance tab and then Find a Provider/Doctor link on the right. You can search for a provider based on defined criteria or by the provider name. Call Aetna through TI HR Connect at Contact Aetna directly by phone at or through the Aetna Navigator Web site at Medical-Aetna HealthFund (HRA) 11

12 Network/Non-Network If you live in or receive care in a location with a network, your benefits will be paid based on your selection of a network or non-network provider. This applies to all non-emergency inpatient, outpatient or pharmacy services. However, if non-network labs or radiology services are used, when in connection with services requested by a network provider, your benefits will be reimbursed at the in-network benefit level. When you travel, you must use a network provider for non-emergency care in order to receive network reimbursement. If you use non-network providers, your benefits will be reimbursed at the non-network level (See section on Emergency Care for information on using non-network providers in an emergency situation.). Network providers have agreed to file the claim and accept a negotiated rate, which results in lower fees for you and TI. Non-network providers are reimbursed according to Recognized Charge calculations. The listing of network providers can be found on the Aetna Navigator Web site at Notes: "Provider" is defined as anyone who is licensed and provides medical services within the scope of their license hospitals, doctors, and outpatient care centers Network or negotiated rates apply to expenses that are covered under the Aetna HealthFund (HRA). Network or negotiated rates do not apply to non-covered expenses. Pre-Certification Certain services, 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 Aetna HealthFund (HRA) option. 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 provided by a network provider. Network providers will be responsible for obtaining necessary precertification for you. Since precertification is the provider s responsibility, and there is no additional out-of-pocket cost to you as a result of a network provider s failure to precertify services. When you go to an out-of-network provider, it is your responsibility to obtain precertification from Aetna for any services or supplies on the precertification list below. Precertification Process Prior to being hospitalized or receiving certain other medical services or supplies there are certain precertification procedures that must be followed. 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 supplement in accordance with the following timelines: 12 Medical-Aetna HealthFund (HRA)

13 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: For an emergency outpatient medical condition: For an emergency admission: For an urgent admission: For outpatient non-emergency medical services requiring precertification: 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. You or your physician should call prior to the outpatient care, treatment or procedure if possible; or as soon as reasonably possible. You, your physician or the facility must call within 48 hours or as soon as reasonably possible after you have been admitted. 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. You or your physician must call at least 14 days before the outpatient care is provided, or the treatment or procedure is scheduled. Aetna will provide a written notification to you and your physician of the precertification decision. If your precertified expenses are approved, the approval is good for 60 days as long as you remain enrolled in this option. When you have an inpatient admission to a facility, Aetna will notify you, your physician and the facility about your precertified length of stay. If your physician recommends that your stay be extended, additional days will need to be certified. You, your physician, or the facility will need to call Aetna at the number on your ID card as soon as reasonably possible, but no later than the final authorized day. Aetna will review and process the request for an extended stay. You and your physician will receive a notification of an approval or denial. If precertification determines that the stay or services and supplies are not covered expenses, the notification will explain why and how Aetna s decision can be appealed. You or your provider may request a review of the precertification decision pursuant to the Claims, Appeals and External Review section included with this supplement. Your Benefits What is Covered under the Aetna HealthFund (HRA) Option This option covers only those services for medical, surgical and behavioral health care that meet the following conditions: The service rendered is medically necessary for the treatment of your injury, disease or pregnancy The service rendered is delivered by an eligible provider (for medical this is a licensed physician acting within the scope of his license, not a resident physician or intern; for behavioral health this is licensed physician, Ph.D. psychologist, licensed professional counselor, licensed marriage and family therapist or masters of social work) The service rendered is covered under this option Medical-Aetna HealthFund (HRA) 13

14 Medically necessary expenses are those services or supplies which are necessary for the diagnosis, care or treatment of an illness and which are determined to be widely accepted professionally in the U.S. as effective, appropriate, and essential, based on recognized standards of the health care specialty involved. You or your provider can contact Aetna to confirm whether an expense is eligible for coverage. Covered Amounts Network Doctor The amount the provider charges for the service is referred to as the billed amount. This amount does not take into account any discounts negotiated with Aetna. The Recognized Charge is the amount covered by this option, as agreed to by the network provider. You or your provider can contact Aetna to confirm whether an expense is eligible for coverage. Case Management Case Management, which is a collaborative process provided as a service to you and your family to facilitate the communication and coordination of care options, may also be available to you. You or your provider can contact Aetna s Case Management Department for assistance with determining available resources and coordination of care options. Case management can be of assistance for catastrophic injuries (such as head, spinal cord, burns, amputations, crush injuries) and catastrophic illnesses (such as strokes, cancer, HIV/AIDS, transplant, aneurism, muscular dystrophy, multiple sclerosis, organ transplants). You can contact Aetna s Case Management Department by calling Aetna through TI HR Connect at Recognized Charge The Recognized Charge is the part of a charge that the Aetna Claims Administrator will pay for eligible expenses you incur under the Aetna HealthFund (HRA) option. The Aetna Claims Administrator has established a Recognized Charge for medically necessary services, supplied and procedures provided by providers that have contracted with the Aetna Claims Administrator and providers that have not contracted with the Aetna Claims Administrator. When you choose to receive services, supplies, or care from a provider that does not contract with the Aetna Claims Administrator, you will be responsible for any difference between the Aetna Claims Administrator s Recognized Charge and the amount charged by such non-network provider. You will also be responsible for charges for services, supplies, and procedures limited or not covered under the Aetna HealthFund HRA option, any applicable deductibles and coinsurance amounts. As to medical, vision and hearing expenses, the Recognized Charge for each service or supply is the lesser of: What the provider bills or submits for that service or supply; and For professional services and other services or supplies not mentioned below (including nonnetwork doctors fees): o the 80th percentile of the Prevailing Charge Rate for the Geographic Area where the service is furnished. As to prescription drug expenses, the Recognized Charge for each service or supply is the lesser of: What the provider bills or submits for that service or supply; and 110% of the Average Wholesale Price (AWP) or other similar resource. Average Wholesale Price (AWP) is the current average wholesale price of a prescription drug listed in the Medi-Span weekly price updates (or any other similar publication chosen by Aetna). 14 Medical-Aetna HealthFund (HRA)

15 If Aetna has an agreement with a provider (directly, or indirectly through a third party) which sets the rate that Aetna will pay for a service or supply, then the Recognized Charge is the rate established in such agreement. In determining the Recognized Charge, Aetna may also reduce the charge by applying Aetna Reimbursement Policies. Aetna Reimbursement Policies address the appropriate billing of services, taking into account factors that are relevant to the cost of the service such as: the duration and complexity of a service; whether multiple procedures are billed at the same time, but no additional overhead is required; whether an assistant surgeon is involved and necessary for the service; if follow up care is included; whether there are any other characteristics that may modify or make a particular service unique; and when a charge includes more than one claim line, whether any services described by a claim line are part of or incidental to the primary service provided. Aetna Reimbursement Policies are based on Aetna's review of: the policies developed for Medicare; the generally accepted standards of medical and dental practice, which are based on credible scientific evidence published in peer-reviewed literature generally recognized by the relevant medical or dental community or which is otherwise consistent with physician or dental specialty society recommendations; and the views of physicians and dentists practicing in the relevant clinical areas. Aetna uses a commercial software package to administer some of these policies. As used above, Geographic Area and Prevailing Charge Rates are defined as follows: Geographic Area: This means an expense area grouping defined by the first three digits of the U.S. Postal Service zip codes. If the volume of charges in a single three digit zip code is sufficient to produce a statistically valid sample, an expense area is made up of a single three digit zip code. If the volume of charges is not sufficient to produce a statistically valid sample, two or more three digit zip codes are grouped to produce a statistically valid sample. When it is necessary to group three digit zip codes, the grouping never crosses state lines. Prevailing Charge Rates: These are rates reported by FAIR Health, a nonprofit company, in their database. FAIR Health reviews and, if necessary, changes these rates periodically. Aetna updates its systems with these changes within 180 days after receiving them from FAIR Health. Important Note: Aetna periodically updates its systems with changes made to the Prevailing Charge Rates. What this means to you is that the Recognized Charge is based on the version of the rates that is in use by Aetna on the date that the service or supply was provided. Additional Information Aetna s website aetna.com may contain additional information which may help you determine the cost of a service or supply. Log on to Aetna Navigator to access the "Estimate the Cost of Care" feature. Within this feature, view our "Cost of Care" and "Member Payment Estimator" tools, or contact our Customer Service Department for assistance. Medical-Aetna HealthFund (HRA) 15

16 What You Will Pay If you have access to a network provider and you choose a non-network provider who charges more than the Recognized Charge, you will be responsible for the difference. Expenses that are Not Covered Expenses for treatment provided which are not covered: Charges for services considered not medically necessary Charges for procedures or services not covered by the Aetna HealthFund (HRA) option Charges that are more than the Recognized Charge Charges for procedures or services delivered by an ineligible provider Pre-Existing Conditions The Aetna HealthFund (HRA) does not impose any limitations on pre-existing conditions. Certificate of Group Health Plan Coverage If you leave TI and are required by another employer to provide proof of your previous TI insurance coverage (certificate of group health plan coverage), contact the TI Benefits Center. This proof may be required to offset any pre-existing condition limitation that may be applied by your new employer or insurance. The TI Benefits Center will provide you with a certificate of group health plan coverage when you lose coverage under the health benefit plan. 16 Medical-Aetna HealthFund (HRA)

17 Deductibles and Coinsurances in the Aetna HealthFund (HRA) You share the cost of coverage through deductibles, copays and coinsurance; the following chart highlights some of the coverage amounts. Aetna HealthFund (HRA) Your Cost Network Non-Network Annual Deductible Medical/ Behavioral Health Care and Pharmacy Annual Deductible - Pharmacy Annual Out-of-Pocket Maximum for Medical/ Behavioral Health Care and Pharmacy 6 Annual Out-of-Pocket Maximum for Pharmacy Deductibles $1,500 individual $3,000 family 1 Included in above $3,000 individual $6,000 family 1 $6,000 individual $12,000 family 1 Included in above Benefit Coinsurance Doctor 2 90% 50% Professional Services 3 90% 50% X-ray and Lab (freestanding facility) 90% 50% X-ray and Lab (outpatient hospital) 80% 50% Hospital/Facilities 4 (inpatient & outpatient) 80% 50% Nutrition 90% 50% Behavioral Health Care 5 (doctor/outpatient) Behavioral Health Care 5 (hospital/inpatient) 90% 50% 80% 50% 4 1 The Aetna HealthFund (HRA) family deductible and annual out-of-pocket maximums apply to you + spouse or domestic partner, you + child and you + family coverage and are met when all medical and pharmacy claims add up to the family deductible and/or maximum outof-pocket amount. 2 If a lead network surgeon is used and services are performed at a network facility and the assistant surgeon is non-network, the claims for the assistant surgeon's services would be reimbursed at the in-network level. If the lead surgeon and the assistant surgeon are both non-network providers, claims for their services would be reimbursed at the non-network level. 3 Professional services include(s), but are not limited to, surgeons, radiologists, anesthesiologists, physical therapists and home health care providers. 4 Facilities include, but are not limited to, hospitals, emergency rooms, skilled nursing facilities and hospice. 5 Behavioral health care must be provided by a licensed M.D., Ph.D. psychologist, licensed professional counselor, licensed marriage and family therapist or master of social work. 6 The annual out-of-pocket maximum for medical/behavioral health care does not include charges not covered by the Aetna HealthFund (HRA) option or exceeding the Recognized Charge or other Aetna HealthFund (HRA) option limits, or the difference between a generic and brand-name drug when a generic is available but a brand-name drug is purchased. Medical-Aetna HealthFund (HRA) 17

18 Lifetime Limits The Aetna HealthFund (HRA) does not impose any lifetime limits, except a 30-day lifetime limit for Hospice Care. Adult Preventive Health Care Preventive health care is designed to help TIers take an active role in managing their health and wellbeing. Targeted preventive care services help detect risks and health problems early when they are easiest to treat. The periodic preventive health office visit, screening tests and immunizations recommended for your age and gender are covered at 100%. No copay, coinsurance or deductibles apply. Preventive services by non-network providers are covered at 100% of the Recognized Charge; however, deductibles and coinsurance amounts do not apply. Unless specifically provided otherwise, charges are not covered as preventive health care for: Services which are covered to any extent under any other part of this Aetna HealthFund (HRA) option; Services which are for diagnosis or treatment of a suspected or identified illness or injury; Exams given during your stay for medical care; Services not given by a physician or under his or her direction; and Psychiatric, psychological, personality or emotional testing or exams. Routine Physical Exams Covered expenses include charges made by your physician for routine physical exams. This includes routine vision and hearing screenings given as part of the routine physical exam. A routine exam is a medical exam given by a physician for a reason other than to diagnose or treat a suspected or identified illness or injury, and also includes: Evidence-based items that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force. For females, screenings and counseling services as provided for in the comprehensive guidelines recommended by the Health Resources and Services Administration. These services may include but are not limited to: o Screening and counseling services, such as: Interpersonal and domestic violence; Sexually transmitted diseases; and Human Immune Deficiency Virus (HIV) infections. o Screening for gestational diabetes. o High risk Human Papillomavirus (HPV) DNA testing for women age 30 and older. X-rays, lab and other tests given in connection with the exam. For covered newborns, an initial hospital check up. Limitations: Unless specified above, not covered under this Preventive Care benefit are charges for: Services which are covered to any extent under any other part of this option; Services which are for diagnosis or treatment of a suspected or identified illness or injury; Exams given during your stay for medical care; 18 Medical-Aetna HealthFund (HRA)

19 Services not given by a physician or under his or her direction; Psychiatric, psychological, personality or emotional testing or exams; Preventive Care Immunizations Covered expenses include charges made by your physician or a facility for immunizations for infectious diseases and the materials for administration of immunizations that have been recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Limitations: Not covered under this Preventive Care benefit are charges incurred for immunizations that are not considered Preventive Care such as those required due to your employment or travel. Flu Vaccinations At most sites, you, your eligible spouse or domestic partner and dependents have access to free onsite flu vaccinations. Or, you, your spouse or domestic partner and dependents can receive your annual flu vaccination at your doctor s office or a TI-preferred health clinic. Children between the ages of 9 and 17 can receive a flu vaccination on-site with parental consent. Children under the age of 9 should receive the flu vaccination from their physician. Such vaccination and accompanying office visit are covered at 100%. If a non-network provider provides the vaccination, services are covered as a Recognized Charge. Well Woman Preventive Visits Covered expenses include charges made by your physician for a routine well woman preventive exam office visit, including Pap smears, in accordance with the recommendations by the Health Resources and Services Administration. A routine well woman preventive exam is a medical exam given by a physician for a reason other than to diagnose or treat a suspected or identified illness or injury. Limitations: Unless specified above, not covered under this Preventive Care benefit are charges for: Services which are covered to any extent under any other part of this option; Services which are for diagnosis or treatment of a suspected or identified illness or injury; Exams given during your stay for medical care; Services not given by a physician or under his or her direction; Psychiatric, psychological, personality or emotional testing or exams. Routine Cancer Screenings Covered expenses include, but are not limited to, charges incurred for routine cancer screening as follows: Mammograms; Fecal occult blood tests; Digital rectal exams; Prostate specific antigen (PSA) tests; Sigmoidoscopies; Double contrast barium enemas (DCBE); and Colonoscopies Medical-Aetna HealthFund (HRA) 19

20 These benefits will be subject to any age; family history; and frequency guidelines that are: Evidence-based items or services that have in effect a rating of A or B in the recommendations of the United States Preventive Services Task Force; and Evidence-informed items or services provided in the comprehensive guidelines supported by the Health Resources and Services Administration. Limitations: Unless specified above, not covered under this Preventive Care benefit are charges incurred for services which are covered to any extent under any other part of this option. Important Note: For details on the frequency and age limits that apply to Routine Physical Exams and Routine Cancer Screenings, contact your physician, log onto the Aetna website or call the member services at the number on the back of your ID card. Prenatal Care Prenatal care will be covered as Preventive Care for services received by a pregnant female in a physician's, obstetrician's, or gynecologist's office but only to the extent described below. Coverage for prenatal care under this Preventive Care benefit is limited to pregnancy-related physician office visits including the initial and subsequent history and physical exams of the pregnant woman (maternal weight, blood pressure and fetal heart rate check). The following screenings/services are covered at 100% if billed as preventive by your provider: Primary care interventions to promote breastfeeding during pregnancy and after birth Rh (D) incompatibility during first prenatal visit, repeated testing for all unsensitized Rh (D) negative women at weeks gestation Tobacco use screening and cessation intervention counseling for pregnant tobacco users Urine culture at 12 to 16 weeks gestation or at the first prenatal visits, if later Hepatitis B screening at first prenatal visit HIV at first prenatal visit, with consent Syphilis screening Gestational diabetes screening for women at 24 to 28 weeks gestation and those at high risk Anemia screening for iron deficient anemia in asymptomatic pregnant women Limitations: Unless specified above, not covered under this Preventive Care benefit are charges incurred for: Services which are covered to any extent under any other part of this option; Pregnancy expenses (other than prenatal care as described above). Comprehensive Lactation Support and Counseling Services Covered expenses include comprehensive lactation support (assistance and training in breast feeding) and counseling services provided to females during pregnancy and in the post partum period by a certified lactation support provider. The "post partum period" means the one-year period directly following the child's date of birth. Covered expenses incurred during the post partum period also include the rental or purchase of breast feeding equipment as described below. Lactation support and lactation counseling services are covered expenses when provided in either a group or individual setting. Benefits for lactation counseling services are subject to the visit maximum. 20 Medical-Aetna HealthFund (HRA)

21 Breast Feeding Durable Medical Equipment Coverage includes the rental or purchase of breast feeding durable medical equipment for the purpose of lactation support (pumping and storage of breast milk) as follows. Breast Pump Covered expenses include the following: The rental of a hospital-grade electric pump for a newborn child when the newborn child is confined in a hospital. The purchase of: An electric breast pump (non-hospital grade), if requested within 60 days from the date of the birth of the child. A purchase will be covered once every three years following the date of the birth; or A manual breast pump, if requested within 12 months from the date of the birth of the child. A purchase will be covered once every three years following the date of the birth. If an electric breast pump was purchased within the previous three year period, the purchase of an electric or manual breast pump will not be covered until a three year period has elapsed from the last purchase of an electric pump. Breast Pump Supplies Coverage is limited to only one purchase per pregnancy in any year where a covered female would not qualify for the purchase of a new pump. Coverage for the purchase of breast pump equipment is limited to one item of equipment, for the same or similar purpose, and the accessories and supplies needed to operate the item. You are responsible for the entire cost of any additional pieces of the same or similar equipment you purchase or rent for personal convenience or mobility. Aetna reserves the right to limit the payment of charges up to the most cost efficient and least restrictive level of service or item which can be safely and effectively provided. The decision to rent or purchase is at the discretion of Aetna. Limitations: Unless specified above, not covered under this Preventive Care benefit are charges incurred for services which are covered to any extent under any other part of this option. Important Note: If a breast pump service or supply that you need is covered under this option but not available from a network provider in your area, please contact Member Services at the toll-free number on your ID card for assistance. Family Planning Services For females with reproductive capacity, covered expenses include those charges incurred for services and supplies that are provided to prevent pregnancy. All contraceptive methods, services and supplies covered under this Preventive Care benefit must be approved by the U.S. Food and Drug Administration (FDA). Coverage includes counseling services on contraceptive methods provided by a physician, obstetrician or gynecologist. Such counseling services are covered expenses when provided in either a group or individual setting. They are subject to the contraceptive counseling services visit maximum shown in your Schedule of Benefits. Medical-Aetna HealthFund (HRA) 21

22 The following contraceptive methods are covered expenses under this Preventive Care benefit: Voluntary Sterilization Covered expenses include charges billed separately by the provider for female voluntary sterilization procedures and related services and supplies including, but not limited to, tubal ligation and sterilization implants. Covered expenses under this Preventive Care benefit would not include charges for a voluntary sterilization procedure to the extent that the procedure was not billed separately by the provider or because it was not the primary purpose of a confinement. Contraceptives Covered expenses include charges made by a physician or pharmacy for female contraceptive devices that including the related services and supplies needed to administer the device. When contraceptive methods are obtained at a pharmacy, prescriptions must be submitted to the pharmacist for processing. Limitations: Unless specified above, not covered under this Preventive Care benefit are charges for: Services which are covered to any extent under any other part of this option; Services and supplies incurred for an abortion; Services provided as a result of complications resulting from a voluntary sterilization procedure and related follow-up care; Services which are for the treatment of an identified illness or injury; Services that are not given by a physician or under his or her direction; Psychiatric, psychological, personality or emotional testing or exams; Any contraceptive methods that are only "reviewed" by the FDA and not "approved" by the FDA; Male contraceptive methods, sterilization procedures or devices; The reversal of voluntary sterilization procedures, including any related follow-up care. Covered expenses include charges for certain family planning services, even though not provided to treat an illness or injury. Voluntary sterilization for males Voluntary termination of pregnancy Limitations: Not covered are: Reversal of voluntary sterilization procedures, including related follow-up care; Charges for services which are covered to any extent under any other part of this option or any other options sponsored by your employer; and Charges incurred for family planning services while confined as an inpatient in a hospital or other facility for medical care. 22 Medical-Aetna HealthFund (HRA)

23 Preventive Health Care for Infants and Children (0 Months-18 Years) Immunizations and Lab Tests Recommended immunizations and the office visit at the time of the immunization are covered. The immunization schedule is based on the recommendations of the American Academy of Pediatrics, the American Academy of Family Practice Physicians and the U.S. Task Force for Preventive Services. This option also covers a Phenylketonuria (PKU) lab test performed at birth and an infant office visit with a PKU lab test two to three weeks following birth. Expenses for recommended immunizations and lab tests are covered at 100%. No copay, coinsurance or deductibles apply. Services by non-network providers are covered at 100% of the Recognized Charge. Reminder: To add coverage for a newborn child or newly adopted child (adopted or placement for adoption), coverage must be elected within 30 days from the date of birth. Infant and Child Check-ups Maximum Exams Under Age 3 First 12 months of life 7 exams 13 th 24 th months of life 3 exams 25 th 36 th months of life 3 exams Ages exam per 12 consecutive month period Screening and Counseling Services for Obesity, Misuse of Alcohol and/or Drugs, Use of Tobacco Products Covered expenses include services by your primary care physician in an individual or group setting, which are subject to the visit maximums shown in the chart that follows. In figuring the visit maximums, each session of up to 60 minutes is equal to one visit.. Obesity Covered expenses include the following screening and counseling services to aid in weight reduction due to obesity: preventive counseling visits and/or risk factor reduction intervention; medical nutrition therapy; nutrition counseling; and healthy diet counseling visits provided in connection with Hyperlipidemia (high cholesterol) and other known risk factors for cardiovascular and diet-related chronic disease. Misuse of Alcohol and/or Drugs Covered expenses include screening and counseling services to aid in the prevention or reduction of the use of an alcohol agent or controlled substance. Coverage includes preventive counseling visits, risk factor reduction intervention and a structured assessment. Use of Tobacco Products Tobacco product means a substance containing tobacco or nicotine including: cigarettes, cigars; smoking tobacco; snuff; smokeless tobacco and candy-like products that contain tobacco. Covered expenses Medical-Aetna HealthFund (HRA) 23

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