Arizona 2-100 Plan Guide

Transcription

Quality health plans & benefits
Healthier living
Financial well-being
Intelligent solutions
Arizona plan guide
Creating the right health benefits package
starts with you and your employees
Plans effective January 1, 2015
For businesses with 2 – 100 eligible employees
www.aetna.com
XX.XX.XXX.X (X/14)
14.03.254.1-AZ
B (7/14)
Choosing the right health plan
Every company has its own particular needs, driven in part
by the health of its employees, by its commitment to health
and wellness and, of course, by its financial resources.
We believe creating the right health benefits and
insurance plan means combining these four options
to meet a company’s specific needs: benefits,
network, cost sharing, funding.
Experience matters
We take the time to listen and learn about your needs. Our
experience allows us to share knowledge and provide tools
to help achieve the right balance of cost and coverage.
Our approach makes all the difference in the value you get
from your plan, and in the satisfaction of your employees.
Today’s health care environment demands a new set of
solutions to meet new challenges. Together, we can create
a healthy future for your company and your employees.
Health benefits and health insurance, dental benefits/dental insurance, life insurance and disability insurance plans/
policies are offered, underwritten or administered by Aetna Health Inc., Aetna Health Insurance Company and/or Aetna
Life Insurance Company (Aetna). Each insurer has sole financial responsibility for its own products.
We want to make choosing the right benefits as easy as possible.
So we’ve organized information in this easy-to-understand guide.
Health care reform
Plans, tools and extras
M
D
V
L&D
U
4
6 – 7
Network options, cost-sharing and premiums 8
Health and wellness programs 9
Medical plans overview
10
Medical plan options
11
Traditional medical plans
23
HMO and HNOption plans
31
Indemnity plan
32
Dental plans overview
34
Aetna dental plans 2 – 9 36
Aetna voluntary dental plans 3 – 9
39
Aetna standard and voluntary
dental plan selections 10 – 100
42
Vision plans overview
46
Aetna Vision Preferred
48
Life and disability plans overview
51
Life plan options
54
Disability plan options – short term
55
Disability plan options – long term
56
Packaged life and disability plan options
57
Underwriting guidelines
58
Limitations and exclusions
81
New business checklist
84
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Changes to your plan due to health care reform
Signed into law in March 2010, the Affordable Care Act is
the most life-changing law since the passing of Medicare in
the 1960s. We are committed to following the new health
care law and to helping you understand its impact.
We have outlined below key changes that may impact your
health care benefits.
Essential health benefits package
Aetna plans must offer standard coverage known as
“essential health benefits.” This includes all plans inside and
outside of the health insurance exchanges. These benefits
provide your employees with essential health benefits, and
limit cost-sharing.
Here are the broad categories of essential benefits that will
be included in your employees’ coverage:
•Ambulatory patient services
•Emergency services
•Hospitalization
•Maternity and newborn care
•Mental health and substance abuse services
•Prescription drugs
•Rehabilitative and habilitative services and devices
•Laboratory services
•Preventive and wellness services and chronic disease
management
•Pediatric dental
•Pediatric vision
Out-of-pocket (OOP) maximum mandate
All cost sharing must apply toward the OOP maximum*,
including in-network medical, behavioral health and
pharmacy cost-sharing. This does not include premiums,
balance billing amounts of non-network providers or
spending for non-covered services.
The out-of-pocket maximum must include:
•Copays
•Deductibles
•Coinsurance
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*Prescription drugs may have a separate out-of-pocket maximum.
**Note: no standalone insured behavioral health.
Fees
These fees are included in your premium:
•Health Insurer Fee — Annual fee to offset premium
subsidies and tax credit related expenses
•Transitional Reinsurance Program Contribution — Helps finance the cost of high-risk individuals in the
individual market
•Patient-Centered Outcomes Research Fee (also known
as the Comparative Effectiveness Fee) — Fee to fund
clinical outcomes effectiveness research
Guaranteed issue
Guaranteed issue of health insurance coverage applies to
individual, small group and large group markets. Guaranteed
Issue is available for:
•Group health plans/insurance coverage (insured only)
•Individual health insurance coverage (including medical
conversion)
•Pharmacy (insured only)
•Behavioral health (insured only)**
Please note that guaranteed issue is not available for:
•Self-funded plans
•Standalone/separate dental or vision
•Hospital indemnity/Fixed indemnity
•Medicare and Medicare supplement
•Medicaid
•Retiree-only plans
•Grandfathered plans
•Association/MEWA plans
Waiting period
Plans may not have any waiting periods longer than 90 days.
The benefit waiting period for future employees may be the
1st or 15th or the month following 0 days, 30 days or 60 days.
The maximum 90-day waiting period applies to fully insured
and self-funded plans. We will update our policies and will
work with employers that have waiting periods exceeding
90 days. Refer to Underwriting Guidelines for details.
Pediatric dental/vision (2 to 50)
Pediatric dental and vision mandates are a separate essential
health benefit category and are included with your medical
benefits. We will cover those services in 2015 according to
the benchmark plan coverage. Pediatric dental and vision is
for children up to age 19.
Pediatric dental*
PPO/HNO plans
HMO plans with
no deductible
Indemnity
PPO HSA plans
Preferred
Nonpreferred
Preferred
Nonpreferred
Preferred
No network
Dental check-up
(preventive/diagnostic)
0% deductible
waived
30% after
deductible
0% after
deductible
30% after
deductible
0%
0% deductible
waived
Dental basic
30% after
deductible
50% after
deductible
30% after
deductible
50% after
deductible
30%
30% after
deductible
Dental major
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50%
50% after
deductible
Dental ortho
(after 24 months
of continuous coverage)
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50%
50% after
deductible
Pediatric vision**
PPO/HNO plans
HMO plans with
no deductible
Indemnity
PPO HSA plans
Preferred
Nonpreferred
Preferred
Nonpreferred
Preferred
No network
Vision exam
(one exam per 12 months)
$0 copay
deductible waived
50% after
deductible
0% deductible
waived
50% after
deductible
$0 copay
deductible waived
0% deductible
waived
Frames, lenses or contacts
(per 12 months)
Preferred:0%
deductible waived
Nonpreferred: 50%
after deductible
50% after
deductible
Preferred: 0% after
deductible
Nonpreferred: 50%
after deductible
50% after
deductible
Preferred: 0%
Nonpreferred: 50%
Preferred: 0%
deductible waived
Nonpreferred: 50%
after deductible
*These medical plans don’t cover all pediatric dental care expenses and include limitations and exclusions. Please refer to your plan
documents to see which services we cover. The following is a partial list of services and supplies that we generally don’t cover.
However, your plan documents may have exceptions to this list. We base these documents on state laws, essential health benefits,
or the plan design or rider(s) you buy.
--All pediatric dental services not specifically covered in, or that your plan documents limit or exclude, including costs of services
before coverage begins and after coverage ends
--Instructions for diet, plaque control and oral hygiene
--Dental services or supplies that you may primarily use to change, improve or enhance appearance
--Dental implants
--Experimental or investigational drugs, devices, treatments or procedures
--Services not necessary for the diagnosis, care or treatment of a condition
--Orthodontic treatment that isn’t medically necessary for a severe or handicapping condition
--Replacement of lost or stolen appliances
--Services and supplies provided where there is no evidence of pathology, dysfunction or disease
**Medically necessary glasses or contact lenses prescribed to treat an eye disease or injury are covered as prosthetics and are not
covered as a pediatric vision expense.
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Choosing the right plan for your business
Our product portfolio includes a range of coverage and cost combinations. You’ll find choices for different budgets and benefits
strategies. And you’ll see that we’re more than medical. You can round out your benefits offering with dental as well as life and
disability offerings.
Take a look at what’s available.
Medical plans
•PPO plans
•Aetna Whole Health plans*
•Savings Plus plans*
•HMO and HNOption plans
Plan levels
You can choose up to four levels of health plans. These levels
are named using metals — bronze, silver, gold and platinum.
Each level includes the same essential health benefits.
But the levels differ in how much the health plan pays.
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Health plan levels
Average amount the plan
pays for covered services
Bronze
60%
Silver
70%
Gold
80%
Platinum
90%
Tools to help your employees stay healthy,
informed and productive
With Aetna health plans, your employees get online tools and
helpful resources that let them make the most of their
benefits. Our most popular tools include:
•Secure member website. Your employees get self-service
tools, plus health plan and health information through their
Aetna Navigator® website. Think of it as the key that unlocks
the full value of their health benefits package. Encourage
them to sign up at www.aetna.com.
•Member Payment Estimator SM tool. With an Aetna health
plan, your employees can compare and estimate costs** for
office visits, tests, surgeries and more. This means they can
save money*** — and avoid surprises. This online tool
factors in their deductible, coinsurance and copays, plus
contracted rates. They can see how much they have to pay
and how much the plan will pay. They can log in to their
Aetna Navigator member website to use the tool.
•Online provider directory. Finding doctors, specialists,
hospitals and more in the Aetna network is easy with our
DocFind® directory. It’s available at www.aetna.com and
the Aetna Navigator member website.
•iTriage. (51 to 100 employees) This is a free mobile app
that lets members research symptoms and diseases, find a
medical provider and even book an appointment — all from
the convenience of their mobile device. iTriage will guide
them to network doctors, hospitals and facilities based on
their company health plan. It can help direct your employees
to the most appropriate, cost-effective care.
*May not be available in all areas.
**E stimated costs not available in all markets. The tool gives members an estimate of what they would owe for a particular service
based on the plan at that point in time. Actual costs may differ from the estimate if, for example, claims for other services are
processed after a member gets the estimate but before the claim for this service is submitted. Or, if the doctor or facility performs
a different service at the time of the visit.
***In 2011, members who used Member Payment Estimator before receiving care saved an average of $170 out of pocket on
34 common procedures, according to the Member Payment Estimator Study, Aetna Informatics and Product Development,
August 2012.
Dental plans
Life and disability plans*
•Dental – DMO®
•Dental – PPO
•Dental – PPO Max
•Dental – Freedom-of-Choice plan design
•Basic life
•Supplemental life
•AD&D Ultra®
•Supplemental AD&D Ultra
•Dependent life
•Packaged life and disability plans
•Short-term disability
•Long-term disability
Dental plan extras
There’s extra value built into our dental portfolio:
•Dental-medical integration. Our program encourages
preventive dental care among employees who have diabetes
or heart disease, or who are pregnant. This can lead to more
of your employees taking steps to stay healthy.
Vision plans
•Aetna VisionSM Preferred (AVP)
--Basic, Plus and Premier plan designs
Vision plan extras
Life and disability plan extras
•Aetna Life EssentialsSM. Through our program, your
employees get access to expert advice on legal and financial
matters — at no added cost.
•Funeral planning and concierge service. Through our
collaboration with Everest, we offer our life members
pre-planning and at-need services .
Routine vision care is important to overall health and
wellness. With our competitive plan options, your employees
will receive both in- and out-of-network coverage for exams,
eyeglass lenses, frames and contact lenses. In addition, they
can save up to 40 percent off the retail costs on products and
services that aren’t covered under the plan when they visit an
in-network provider. Your employees can choose from our
extensive network of over 65,000 vision providers1, including
their neighborhood eye doctors, as well as their favorite retail
chains. Like LensCrafters®, Pearle Vision®, Sears Optical®,
Target Optical® and JCPenney Optical.
*For groups 51 to 100, please consult your sales representative for a plan design to meet your group needs.
1Data as of June 2014, EyeMed network database.
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You get a wide range of health care options
to fit your needs.
About our benefits
Choose from numerous, integrated benefits options that
can lead to improved employee engagement and health,
while helping you manage your costs. This includes medical,
pharmacy, dental, life, disability and vision. Plus, online tools
that help employees use their benefits wisely and get help
when they need it.
About our network
We have many full-network and tiered-network options to
lower employer costs while still providing employees with
access to quality care. Our doctor networks prioritize quality
and efficiency to improve the health care experience and
make it easy for individuals to get the care they need.
About our cost sharing
Some of our cost-sharing arrangements encourage
employees to become more involved in their own health care
and become better health care consumers. Employees with
these plans receive more preventive care, have lower overall
costs and use online tools more frequently.
About our funding options
We can show you how a combined network, cost sharing and
benefits approach can help you manage your premium to
meet your budget. We also offer a range of funding options —
from traditional fully insured to enhanced self-insured
solutions — that provide different levels of cost, plan control
and information access.
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Network options for healthy outcomes
and lower costs
Our network solutions help lower your costs while providing
employees with access to trusted doctors and hospitals. Your
employees can still get care within the broad Aetna network.
But they pay less out of pocket when they use doctors and
hospitals in our special networks. The more they use health
care providers in these networks, the more likely you are to
see lower medical costs.
We make it easier for your employees, too. They get
online tools for estimating costs and finding the right
doctors and hospitals.
Cost sharing and premiums for every budget
Your focus is on lower costs. Increasingly, that means greater
levels of employee cost sharing. With Aetna in your corner,
you can map out a strategy based on your employee base and
price point. And you can choose from the full spectrum of
health plan types:
•Our fully insured portfolio, traditionally a mainstay for
small businesses, provides plans with a range of robust
coverage options.
•New self-funded options for small businesses may help you
manage costs while simplifying administration and making
monthly expenses more predictable.
•Our defined contribution offering combines an attractive
benefits package with more controlled costs. As well as
motivation for your employees to get more involved in their
health care.
•Our consumer-directed health plans have long offered fully
featured coverage, along with lower premiums and higher
deductibles. Our research has found that members with
these plans have lower overall health care costs, receive
more preventive care and use online tools more frequently
than members with traditional plans.
Health and wellness programs
Women’s preventive health benefits
Having a happier, healthier workforce is important to you.
So is cost management. We’ve found that helping your
employees get more involved in managing their health
and well-being is a great way to meet these goals. Talk to
your broker or Aetna representative to learn more about
our programs.
These services are generally covered at no cost share, when
provided in network:
Wellness on us
Wellness for employees means a healthier business for
employers. As always, our health benefits and insurance
plans offer $0 copays for in-network eye exams and
$0 copay for in-network preventive care. It’s one more way
to help employees get a step closer to better health.
Preventive care benefits with no copay:
•Immunizations
•Routine physicals
•Child wellness visits
•Routine mammogram
•Routine OB/GYN visits
No-cost health incentive credit
Members earn an out-of-pocket expense credit when they:
•Complete or update their Simple Steps To A Healthier Life®
health assessment, and
•Complete one online health program
If the employee’s spouse is covered under the plan, he or
she is also eligible for the same incentive credit. 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.
•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 are covered without member copayment;
certain religious organizations or religious employers may
be exempt from offering contraceptive services
We make things easy for you
Health plan management and administration is our specialty,
which makes it easier for you to manage health insurance
benefits with**:
•eEnrollment. Handle enrollments, terminations and other
changes online, with less paperwork and greater efficiency.
•eBilling. Save time and simplify reconciliation and payment,
anytime, anywhere, with our secure system. It lets you get,
view and pay all your medical and dental bills online.
Wellness programs can make health and fitness part
of everyday living
•Women’s health and preventive health reminders
•Simple Steps To A Healthier Life® program
•Informed Health® Line*
•Aetna discount programs
•Personal health record
*While only your doctor can diagnose, prescribe or give medical advice, the Informed Health Line nurses can provide information
on more than 5,000 health topics. Contact your doctor first with any questions or concerns regarding your health care needs.
**Not available for Aetna Vision Preferred.
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Aetna medical overview
Medical coverage can be a deal-breaker
in recruiting and keeping talented
employees. Our medical plan portfolio
was designed with the needs of
businesses like yours in mind. You’ll
find flexible options, from traditional
indemnity to consumer-directed plans.
You can choose the plan design and
benefits level that fits your budget
and achieve the right balance of cost
and coverage for your business.
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Medical
overview
Aetna high-deductible HSA-compatible health plans
Health reimbursement arrangement (HRA)
High-deductible HSA-compatible plans provide integrated
medical and pharmacy benefits. Preventive care services are
exempt from the deductible.
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 and fund rollover. The fund is available to an
employee for qualified expenses on the plan’s effective date.
HSAs provide employers and their qualified employees with
an affordable tax-advantaged solution that allows them to
better manage their qualified medical and dental expenses.
•Employees can build a savings fund to help cover their
future medical and dental expenses. HSA accounts can be
funded by the employer or employee and are portable.
•Fund contributions may be tax deductible (limits apply).
•When funds are used to cover qualified out-of-pocket
medical and dental expenses, they are not taxed.
It is completely at the discretion of the employer or employee
whether or not to establish an HSA.
Note: Employers and employees should consult with their
tax advisor to determine eligibility requirements and tax
advantages for participation in the HSA plan.
Health savings account (HSA)
No set-up or administrative fees
The Aetna HealthFund® HSA, when coupled with
a HSA-compatible high-deductible health benefits and
health insurance plan, is a tax-advantaged savings account.
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
•Member owns the HSA
•Contribute tax free
•Member chooses how and when to use fund dollars
•Roll it over each year and let it grow
•Earns interest, tax free
Today and into the future
•Use now for qualified expenses with tax-free dollars
•Save for future and retiree health-related costs
High-deductible health plan
•Eligible in-network preventive care services will not be
subject to the deductible
•Member pays 100 percent until deductible is met, then only
pays a share of the cost
•Meet out-of-pocket maximum, then plan pays 100 percent
The HRA and the HSA provide members with financial
support for higher out-of-pocket health care expenses.
Our 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.
COBRA administration
Aetna COBRA administration offers a full range of
notification, documentation and record-keeping processes
that can help employers manage the complex billing and
notification processes 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. First-year POP fees
are waived with the purchase of medical with five or more
enrolled employees.
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.
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.
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Administrative fees
Fee description
Fee
Premium-only plan (POP)
Initial set-up*
Renewal fee
$190
$125
Health reimbursement arrangement (HRA)
and flexible spending account (FSA)**
Initial set-up
Renewal fee
2 – 25 Employees
$360
$235
26 – 50 Employees
$460
$285
51 – 100 Employees
$560
$335
Monthly fees***
$5.45 per participant
Additional set-up fee
for “stacked” plans
(those electing an Aetna HRA
and FSA simultaneously)
$150
Participation fee
for “stacked” participants
Minimum fees
0 – 25 Employees
$25 per month minimum
COBRA services
Annual fee
20 – 50 Employees
$165
$230
Per employee per month
20 – 50 Employees
$0.95
$1.05
Initial notice fee
$3.00 per notice
(includes notices at time of
implementation and during
ongoing administration)
Minimum fees
20 – 50 Employees
Transit reimbursement account (TRA)
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Annual fee
$350
Transit monthly fees
Parking monthly fees
*Nondiscrimination 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 us for more 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.
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.
We reserve the right to change any of the above fees and to impose additional fees upon prior written notice.
Arizona provider network has more than
18,000 physicians and 95 hospitals*
Aetna PPO plans
Aetna HMO plans
The Aetna PPO insurance plan offers members the freedom
to go directly to any recognized provider for covered
expenses, including specialists. The PPO network is suitable
for in-state rural areas. No referrals are required.
Members access care through primary care physicians
PPO Network = 18,401 providers and 95 hospitals
Aetna Whole Health plans
Banner Health Network (BHN) and Arizona Care
Network (ACN)
The Aetna Whole Health plans provide Arizona members
in the greater Phoenix area with the same types of coverage
as other Aetna medical plans, but at a lower premium cost.
Savings are generated through the use of the Aetna
Whole Health network, a quality network of local health
care providers.
Aetna Whole Health Network featuring:
Banner Health Network = 5,853 providers and 19 hospitals
Arizona Care Network = 3,985 providers and 15 hospitals
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With this health benefits plan, members begin by selecting
a primary care physician (PCP) from our participating network
of providers. Members select a PCP who will coordinate
their health care needs for covered benefits or services.
Each covered member of the family may choose his or her
own PCP.
HMO Network = 18,162 providers and 95 hospitals
Aetna HNOption plans – No referrals
No need for referrals. Aetna HNOption offers all the health
plan benefits of a point-of-service plan with two easy ways
to access care when members need it. Members have the
freedom to visit the participating doctor or hospital of their
choice for covered services. Best of all, members seeking
health care do not need referrals.
HNO Network = 18,162 providers and 95 hospitals
For more information on Savings Plus and Aetna Whole
Health plans, see pages 15 – 22.
Aetna Savings Plus plans
The Aetna Savings Plus plans provide Arizona members in
Maricopa, Pima and Pinal counties with the same types of
coverage as other Aetna medical plans, but at a lower
premium cost. Savings are generated through the use of
the Savings Plus network, a quality network of local health
care providers.
Savings Plus Network = 11,419 providers and 46 hospitals
*According to the Aetna Enterprise Provider Database as of April 2014. Network subject to change.
Employers and employee must reside in an eligible area. Live/work rules apply.
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What is Pick-A-Plan 4?*
Pick-A-Plan 4 is our suite of plans designed specifically with
small businesses in mind. These plans provide choice,
flexibility and simplicity.
Target Audience
Every small business with
5+ enrolled employees.
Pick-A-Plan 4 offers the following advantages:
Plan Choices
Up to 4 available plans
Greater employee choice
Minimum Participation
Employers can offer any four of the available plan designs.
Flexibility and affordability
Employers can create a customized benefits package from
any of our plan types and plan designs. We offer a variety
of plans at different price points.
Employers may designate a level of contribution that meets
their budget.
Total freedom
You can choose from plans that range in price and benefits
to help meet each 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. T
he employer chooses up to four 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.
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Pick-A-Plan 4
*Available with five or more enrolled employees.
2 – 4 Enrolled Employees Single, dual or triple
5 or More Enrolled
Employees
Up to four available options
Employer Contribution
50% of the employee rate or $120
Rating Options
2 – 50 employees – age banded;
51 – 100 employees – composite
Aetna Whole Health (AWH) Options in the Phoenix
Metropolitan Area
We’re proud to offer two Accountable Care Organizations
(ACOs) in the greater Phoenix metropolitan area for you
to choose from!
Both ACOs are high quality provider networks that are
working with Aetna to help improve care while decreasing
costs for members and employers. Your employees will find
care in their own communities, with local health care
providers who have skill, experience, and compassion.
Both the Arizona Care Network (ACN) and the Banner Health
Network (BHN) provide convenient access to an integrated
network of health care providers and facilities dedicated to
patient-centered team approach that delivers a better patient
experience at a much lower cost.
Two key ingredients make the difference in our ACOs
•A better health care experience enabled by
doctor-driven care, technology-based information
sharing, and care coordination
•New payment models and incentives that encourage
accountability to help improve patient health
Better health, better care, better cost
That’s what the Aetna Whole Health product with our
ACOs is designed for. It’s a member-centered approach
that may differ from care your employees have had before
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Find Aetna Whole Health – Arizona Care
Network doctors:
•Visit www.aetna.com/docfind.
•Type a name, specialty, procedure or condition in the “What
are you looking for?” box OR search from a list of conditions,
procedures and provider types.
•Enter your ZIP Code or city and state.
•Select the “Aetna Whole Health – Arizona Care Network”
health benefits plan from the drop-down menu.
•Look for doctors and facilities with the Aetna Whole Health
symbol.
Find Aetna Whole Health – Banner Health
Network doctors:
•Visit www.aetna.com/docfind.
•Type a name, specialty, procedure or condition in the “What
are you looking for?” box OR search from a list of conditions,
procedures and provider types.
•Enter your ZIP Code or city and state.
•Select the “Aetna Whole Health – Banner Health Network
OAMC” health benefits plan from the drop-down menu.
•Look for doctors and facilities with the Aetna Whole Health
symbol.
•The ACO care team’s goal is to help keep your employees
healthy or help improve their health, not just treat them
when they’re sick or injured
•The ACO care team can better coordinate care because they
can see how other doctors are treating your employees, what
medicine they’re taking, lab results, health history and more
•The ACO care team is up-to-date on medical guidelines and
clinical information. This helps to spot problems early and
develop personalized care plans for your employees
•The ACO team wants your employees to take an active and
informed role in their health and health care decisions
All plans are designed to have two levels of benefits
•Level 1: When members use the designated network to
coordinate all of their care, they realize maximum savings.
•Level 2: Use of any other providers will result in a lower level
of benefits.
Employers and employee must reside in an eligible area. Live/work rules apply.
15
M
Arizona Care Network coverage area
Anthem
Glendale
17
60
North Scottsdale
101
Peoria
Scottsdale
Litchﬁeld Park
101
101
202
10
Apache Junction
60
Goodyear
202E
10
Mesa
Maricopa County
Maricopa
San Tan Valley
Gilbert
Pinal County
Find Aetna Whole HealthSM – Arizona Care Network doctors:
• Visit www.aetna.com/docfind
• Type a name, specialty, procedure or condition in the
“Who or what are you looking for?” box
• Enter your ZIP Code or city and state in the “Where?” box
• Choose (AZ) Aetna Whole Health – Arizona Care Network from the
“Select a Plan” drop down menu
16
n Aetna Whole Health Banner Network doctor
Hospitals
Primary care physicians
Urgent care facilities
M
Hospital
ZIP
City
Address
Arizona Orthopedic Surgical Hospital
85224
Chandler
2905 W Warner Rd.
Chandler Regional Medical Center
85224
Chandler
1955 W Frye Rd.
Mercy Gilbert Medical Center
85297
Gilbert
3555 S Val Vista Dr.
Phoenix Children’s – Mercy Gilbert Center
Specialty Care
85297
Gilbert
Arrowhead Hospital
85308
Glendale
18701 N 67th Ave.
HealthSouth Valley of the Sun
Rehabilitation Hospital
85304
Glendale
13460 N 67th Ave.
St. Joseph’s Westgate Medical Center
85305
Glendale
7300 N 99th Ave.
West Valley Hospital Medical Center
85395
Goodyear
13677 W McDowell Rd.
HealthSouth East Valley Rehabilitation Hospital
85206
Mesa
5652 E Baseline Rd.
Arizona Heart Hospital
85016
Phoenix
1930 E Thomas Rd.
Maryvale Hospital
85031
Phoenix
5102 W Campbell Ave.
OASIS Hospital
85008
Phoenix
750 N 40th St.
Paradise Valley Hospital
85032
Phoenix
3929 E Bell Rd.
Phoenix Baptist Hospital
85015
Phoenix
2000 W Bethany Home Rd.
Phoenix Children’s Hospital
85006
Phoenix
1919 E Thomas Rd.
St. Joseph’s Hospital and Medical Center
85013
Phoenix
350 W Thomas Rd.
HealthSouth Scottsdale Rehabilitation Hospital
85260
Scottsdale
9630 E Shea Blvd.
17
M
Banner Health Network coverage area
Anthem
Wickenburg
17
Glendale
North Scottsdale
60
101
Peoria
Litchﬁeld Park
Scottsdale
101
101
10
Apache Junction
202
60
Goodyear
Mesa
202E
10
Maricopa County
Gilbert
San Tan Valley
Maricopa
Pinal County
Find Aetna Whole HealthSM – Banner Health Network doctors:
• Visit www.aetna.com/docfind
• Type a name, specialty, procedure or condition in the “Who or what
are you looking for?” box
• Enter your ZIP Code or city and state in the “Where?” box
• Choose the (AZ) Aetna Whole Health – Banner Health Network plan
from the “Select a Plan” drop down menu
18
Hospitals
Health centers
M
Hospital
Address
Health center
Address
Banner Goldfield
Medical Center
2050 W Southern Ave.
Apache Junction, 85120
Banner Health Center
at Verrado
20751 W Market St.
Buckeye, 85396
Banner Gateway
Medical Center
1900 N Higley Rd.
Gilbert, 85234
in Chandler
1435 S Alma School Rd.
Chandler, 85286
Banner Thunderbird
Medical Center
5555 W Thunderbird Rd.
Glendale, 85306
in Gilbert
155 E Warner Rd.
Gilbert, 85296
Banner Baywood
Medical Center
6644 E Baywood Ave.
Mesa, 85206
at Estrella
9780 S Estrella Pkwy.
Goodyear, 85338
in Maricopa
17900 N Porter Rd.
Maricopa, 85138
in East Mesa
1917 S Crismon Rd.
Mesa, 85209
Banner Desert
Medical Center
Cardon Children’s
Medical Center
1400 S Dobson Rd.
Mesa, 85202
Banner Heart Hospital
6750 E Baywood Ave.
Mesa, 85206
in Queen Creek
21772 S Ellsworth Loop Rd.
Queen Creek, 85142
Banner Estrella
Medical Center
9201 W Thomas Rd.
Phoenix, 85037
in Surprise
13995 W Statler Blvd.
Surprise, 85374
Banner Good Samaritan
Medical Center
1111 E McDowell Rd.
Phoenix, 85006
Banner Ironwood
Medical Center
37000 N Gantzel Rd.
San Tan Valley, 85140
Banner Behavioral
Health Hospital
7575 E Earll Dr.
Scottsdale, 85251
Banner Boswell
Medical Center
10401 W Thunderbird Blvd.
Sun City, 85351
Banner Del E. Webb
Medical Center
14502 W Meeker Blvd.
Sun City West, 85375
19
M
Savings Plus Network Map
10
Maricopa
County
Pinal County
8
Pima County
Find Aetna Savings Plus doctors:
• Visit www.aetna.com/docfind.
• Type a name, specialty, procedure or condition in the “What are you looking for?”
box OR search from a list of conditions, procedures and provider types.
• Enter your ZIP Code or city and state.
• Select the Savings Plus Plans: Savings Plus of Arizona from the drop down menu.
20
Hospitals
M
Hospital
ZIP
City
Address
Casa Grande Regional Medical Center
85122
Casa Grande
1800 E Florence Blvd.
Arizona Orthopedic Surgical Hospital
85224
Chandler
2905 W Warner Rd.
Chandler Regional Medical Center
85224
Chandler
1955 W Frye Rd.
Mercy Gilbert Medical Center
85297
Gilbert
Arrowhead Hospital
85308
Glendale
18701 N 67th Ave.
Banner Thunderbird Medical Center
85306
Glendale
5555 W Thunderbird Rd.
St. Joseph¹s Westgate Medical Center
85307
Glendale
7300 North 99th Avenue
West Valley Hospital Medical Center
85395
Goodyear
13677 W McDowell Rd.
Arizona Spine and Joint Hospital
85206
Mesa
4620 E Baseline Rd.
Cardon Children’s Medical Center
85202
Mesa
1400 S Dobson Rd.
Mountain Vista Medical Center
85209
Mesa
1301 S Crimson Rd.
Oro Valley Hospital
85755
Oro Valley
1551 E Tangerine Rd.
North Peoria Emergency Center
85383
Peoria
26900 N Lake Pleasant Pkwy.
Arizona Heart Hospital
85016
Phoenix
1930 E Thomas Rd.
Los Ninos Hospital
85016
Phoenix
2303 E Thomas Rd.
Maryvale Hospital
85031
Phoenix
5102 W Campbell Ave.
OASIS Hospital
85008
Phoenix
750 N 40th St.
Paradise Valley Hospital
85032
Phoenix
3929 E Bell Rd.
Phoenix Baptist Hospital
85015
Phoenix
2000 W Bethany Home Rd.
Phoenix Children’s Hospital
85016
Phoenix
1919 E Thomas Rd.
Phoenix Indian Medical Center
85016
Phoenix
4212 N 16th St.
St. Joseph’s Hospital and Medical Center
85013
Phoenix
350 W Thomas Rd.
St. Luke’s Medical Center
85006
Phoenix
1800 E Van Buren
Surgical Specialty Hospital of Arizona
85015
Phoenix
6501 N 19th Ave.
21
M
Hospital
22
ZIP
City
Address
Scottsdale Healthcare Greenbaum
Surgical Specialty Hospital
85251
Scottsdale
3535 N Scottsdale Rd.
Scottsdale Healthcare Osborn Medical Center
85251
Scottsdale
7400 E Osborn Rd.
Scottsdale Healthcare Shea Medical Center
85260
Scottsdale
9003 E Shea Blvd.
Scottsdale Healthcare Thompson Peak Hospital
85255
Scottsdale
7400 E Thompson Peak Pkwy.
Tempe St. Luke’s Hospital, A Campus of St. Luke’s 85281
Tempe
1500 S Mill Ave.
Carondelet St. Joseph’s Hospital
85711
Tucson
350 N Wilmot Rd.
Carondelet St. Mary’s Hospital
85745
Tucson
1601 W St. Marys Rd.
Northwest Medical Center
85741
Tucson
6200 N La Cholla Blvd.
Tucson Medical Center
85712
Tucson
5301 E Grant Rd.
University Physicians Hospital at Kino
85713
Tucson
2800 E Ajo Way
M
Gold 500 80/50 (2 – 50)
500 80/50 (51 – 100)
Gold 750 80/50 (2 – 50)
750 80/50 (51 – 100)
Networks available
Open Choice PPO,
Aetna Whole Health Arizona Care Network OAMC,
Aetna Whole Health Banner Health Network OAMC,
Savings Plus of AZ
Open Choice PPO,
Savings Plus of AZ
Member benefits*
Network care
Out-of-network care
Network care
Out-of-network care
Calendar year deductible
$500/$1,000
$1,000/$2,000
$750/$1,500
$1,500/$3,000
Calendar year out-of-pocket limit
$3,750/$7,500
$7,500/$15,000
$3,750/$7,500
$7,500/$15,000
Plan name
Deductible & out-of-pocket limit accumulation1
Embedded
Embedded
Primary care physician office visit
$20 copay; deductible
waived
50% after deductible
waived
Specialist office visit
waived
waived
Walk-in clinics
waived
waived
Diagnostic testing: Lab
waived
waived
Diagnostic testing: X-ray
waived
waived
Imaging (CT/PET scans MRIs)
Inpatient hospital facility
Outpatient surgery
20% after deductible at
ASC; 30% after deductible
at hospital
at hospital
Emergency room
(copay waived if admitted)
waived
Paid as in-network
waived
Paid as in-network
Urgent care
waived
waived
Rehabilitation services (PT/OT/ST)2
Coverage is limited to 60 visits per calendar year
PT/OT/ST combined.
Chiropractic
waived
waived
Pharmacy**
Network
Out of network
Network
Out of network
Pharmacy deductible
None
None
None
None
Preferred generic drugs***
T1: $15 copay
T1: $15 copay plus 20%
T1: $15 copay
Preferred brand drugs
$50 copay
$50 copay plus 20%
$50 copay
$50 copay plus 20%
Nonpreferred drugs †
$80 copay
$80 copay plus 20%
$80 copay
$80 copay plus 20%
Specialty drugs ††
P: 30% up to $300;
NP: 50% up to $500
P: 30% up to $300;
NP: 50% up to $500
P: 30% up to $300;
NP: 50% up to $500
P: 30% up to $300;
NP: 50% up to $500
Refer to page 33 for footnotes.
23
M
Gold 1000 80/50 (2 – 50)
1000 80/50 (51 – 100)
Gold 1000 70/50 (2 – 50)
1000 70/50 (51 – 100)
Networks available
Open Choice PPO,
Savings Plus of AZ
Open Choice PPO,
Savings Plus of AZ
Member benefits*
Network care
Out-of-network care
Network care
Out-of-network care
$1,000/$2,000
$2,000/$4,000
$1,000/$2,000
$2,000/$4,000
$4,500/$9,000
$9,000/$18,000
$4,000/$8,000
$8,000/$16,000
Plan name
24
Embedded
Embedded
waived
waived
waived
waived
Walk-in clinics
waived
waived
20% deductible waived
Outpatient surgery
at hospital
at hospital
Emergency room
waived
Paid as in-network
waived
Paid as in-network
Urgent care
waived
waived
PT/OT/ST combined.
Chiropractic
waived
waived
Pharmacy**
Network
Out of network
Network
Out of network
Pharmacy deductible
None
None
None
None
T1: $15 copay
T1: $15 copay
$50 copay
$50 copay plus 20%
$50 copay
$50 copay plus 20%
$80 copay
$80 copay plus 20%
$80 copay
$80 copay plus 20%
P: 30% up to $300;
NP: 50% up to $500
P: 30% up to $300;
NP: 50% up to $500
P: 30% up to $300;
NP: 50% up to $500
P: 30% up to $300;
NP: 50% up to $500
M
Silver 1500 70/50 (2 – 50)
1500 70/50 (51 – 100)
Silver 2000 70/50 (2 – 50)
2000 70/50 (51 – 100)
Networks available
Open Choice PPO,
Savings Plus of AZ
Open Choice PPO,
Savings Plus of AZ
Member benefits*
Network care
Out-of-network care
Network care
Out-of-network care
$1,500/$3,000
$3,000/$6,000
$2,000/$4,000
$4,000/$8,000
$6,600/$13,200
$13,200/$26,400
$6,600/$13,200
$13,200/$26,400
Plan name
Embedded
Embedded
waived
waived
waived
waived
Walk-in clinics
waived
waived
waived
waived
waived
waived
Outpatient surgery
at hospital
at hospital
Emergency room
waived
Paid as in-network
waived
Paid as in-network
Urgent care
waived
waived
PT/OT/ST combined.
Chiropractic
waived
waived
Pharmacy**
Network
Out of network
Network
Out of network
Pharmacy deductible
None
None
None
None
T1: $15 copay
T1: $15 copay
$50 copay
$50 copay plus 20%
$50 copay
$50 copay plus 20%
$80 copay
$80 copay plus 20%
$80 copay
$80 copay plus 20%
P: 30% up to $300;
NP: 50% up to $500
P: 30% up to $300;
NP: 50% up to $500
P: 30% up to $300;
NP: 50% up to $500
P: 30% up to $300;
NP: 50% up to $500
25
M
Silver 2500 80/50 (2 – 50)
2500 80/50 (51 – 100)
Silver 2500 70/50 (2 – 50)
2500 70/50 (51 – 100)
Networks available
Open Choice PPO,
Savings Plus of AZ
Open Choice PPO,
Savings Plus of AZ
Member benefits*
Network care
Out-of-network care
Network care
Out-of-network care
$2,500/$5,000
$5,000/$10,000
$2,500/$5,000
$5,000/$10,000
$6,600/$13,200
$13,200/$26,400
$6,600/$13,200
$13,200/$26,400
Plan name
26
Embedded
Embedded
waived
waived
waived
waived
Walk-in clinics
waived
waived
waived
waived
waived
waived
Outpatient surgery
at hospital
at hospital
Emergency room
waived
Paid as in-network
waived
Paid as in-network
Urgent care
waived
waived
PT/OT/ST combined.
Chiropractic
waived
waived
Pharmacy**
Network
Out of network
Network
Out of network
Pharmacy deductible
None
None
None
None
T1: $15 copay
T1: $15 copay
$50 copay
$50 copay plus 20%
$50 copay
$50 copay plus 20%
$80 copay
$80 copay plus 20%
$80 copay
$80 copay plus 20%
P: 30% up to $300;
NP: 50% up to $500
P: 30% up to $300;
NP: 50% up to $500
P: 30% up to $300;
NP: 50% up to $500
P: 30% up to $300;
NP: 50% up to $500
M
Bronze 4500 50/50 (2 – 50)
4500 50/50 (51 – 100)
Silver 5000 70/50 (2 – 50)
5000 70/50 (51 – 100)
Networks available
Open Choice PPO,
Savings Plus of AZ
Open Choice PPO,
Savings Plus of AZ
Member benefits*
Network care
Out-of-network care
Network care
Out-of-network care
$4,500/$9,000
$9,000/$18,000
$5,000/$10,000
$10,000/$20,000
$6,600/$13,200
$13,200/$26,400
$6,600/$13,200
$13,200/$26,400
Plan name
Embedded
Embedded
waived
waived
waived
Walk-in clinics
waived
waived
waived
waived
Outpatient surgery
50 % after deductible
at hospital
Emergency room
Paid as in-network
waived (copay waived if
admitted)
Paid as in-network
Urgent care
waived
PT/OT/ST combined.
Chiropractic
waived
Pharmacy**
Network
Out of network
Network
Out of network
Pharmacy deductible
Integrated with Medical
Deductible
Integrated with Medical
Deductible
None
None
T1: $15 copay
T1: $15 copay
$70 copay after deductible $70 copay plus 20% after
deductible
$50 copay
$50 copay plus 20%
$100 copay after
deductible
$100 copay plus 20% after $80 copay
deductible
$80 copay plus 20%
P: 30% up to $300 after
P: 30% up to $300;
deductible; NP: 50% up to deductible; NP: 50% up to NP: 50% up to $500
$500 after deductible
P: 30% up to $300;
NP: 50% up to $500
27
M
Silver 3500 100/50 (2 – 50)
3500 100/50 (51 – 100)
Silver 5000 100/50 (2 – 50)
5000 100/50 (51 – 100)
Networks available
Open Choice PPO,
Savings Plus of AZ
Open Choice PPO,
Savings Plus of AZ
Member benefits*
Network care
Out-of-network care
Network care
Out-of-network care
$3,500/$7,000
$7,000/$14,000
$5,000/$10,000
$10,000/$20,000
$6,600/$13,200
$13,200/$26,400
$6,600/$13,200
$13,200/$26,400
Plan name
28
Embedded
Embedded
waived
waived
waived
waived
Walk-in clinics
waived
waived
waived
waived
waived
waived
Covered in full after
deductible
deductible
deductible
deductible
Outpatient surgery
deductible
deductible
Emergency room
waived
Paid as in-network
waived
Paid as in-network
Urgent care
waived
waived
PT/OT/ST combined.
deductible
deductible
Chiropractic
waived
waived
Pharmacy**
Network
Out of network
Network
Out of network
Pharmacy deductible
None
None
None
None
T1: $15 copay
T1: $15 copay
$50 copay
$50 copay plus 20%
$50 copay
$50 copay plus 20%
$80 copay
$80 copay plus 20%
$80 copay
$80 copay plus 20%
P: 30% up to $300;
NP: 50% up to $500
P: 30% up to $300;
NP: 50% up to $500
P: 30% up to $300;
NP: 50% up to $500
P: 30% up to $300;
NP: 50% up to $500
M
Bronze 6350 100/50 (2 – 50)
6350 100/50 (51 – 100)
Silver 2600 100/50 HSA (2 – 50)
2600 100/50 HSA (51 – 100)
Networks available
Open Choice PPO,
Savings Plus of AZ
Open Choice PPO,
Savings Plus of AZ
Member benefits*
Network care
Out-of-network care
Network care
Out-of-network care
$6,350/$12,700
$12,700/$25,400
$2,600/$5,200
$5,200/$10,400
$6,600/$13,200
$15,750/$31,500
$6,450/$12,900
$12,900/$25,800
Plan name
Embedded
Embedded
waived
deductible
$50 copay after deductible 50% after deductible
deductible
Walk-in clinics
waived
deductible
deductible
deductible
deductible
deductible
deductible
deductible
Outpatient surgery
deductible
deductible
Emergency room
deductible
Paid as in-network
deductible
Paid as in-network
Urgent care
waived
deductible
PT/OT/ST combined.
deductible
deductible
Chiropractic
deductible
Pharmacy**
Network
Out of network
Network
Out of network
Pharmacy deductible
$250 per member
waived T1
$250 per member
waived T1
Integrated with medical
deductible
deductible
T1: $20 copay
T1: $15 copay after
deductible
after deductible
deductible
$100 copay after
deductible
deductible; NP: 50% up to deductible; NP: 50% up to deductible; NP: 50% up to deductible; NP: 50% up to
deductible
$100 copay plus 20% after $80 copay after deductible $80 copay plus 20% after
deductible
deductible
29
M
Bronze 4000 80/50 HSA (2 – 50)
4000 80/50 HSA (51 – 100)
Bronze 5000 100/50 HSA (2 – 50)
5000 100/50 HSA (51 – 100)
Networks available
Open Choice PPO,
Savings Plus of AZ
Open Choice PPO,
Savings Plus of AZ
Member benefits*
Network care
Out-of-network care
Network care
Out-of-network care
$4,000/$8,000
$8,000/$16,000
$5,000/$10,000
$10,000/$20,000
$6,450/$12,900
$12,900/$25,800
$6,450/$12,900
$12,900/$25,800
Plan name
30
Embedded
Embedded
deductible
deductible
Walk-in clinics
deductible
deductible
deductible
deductible
deductible
Outpatient surgery
deductible
Emergency room
Paid as in-network
deductible
Paid as in-network
Urgent care
deductible
PT/OT/ST combined.
deductible
Chiropractic
deductible
Pharmacy**
Network
Out of network
Network
Out of network
Pharmacy deductible
deductible
deductible
deductible
deductible
T1: $15 copay after
deductible
after deductible
T1: $15 copay after
deductible
after deductible
deductible
deductible
deductible
deductible
deductible; NP: 50% up to deductible; NP: 50% up to deductible; NP: 50% up to deductible; NP: 50% up to
M
HMO and HNOption plans
Gold HMO 25/50/500 (2 – 50)
HMO 25/50/500 (51 – 100)
Silver HNOption 1500 70/50 (2 – 50)
HNOption 1500 70/50 (51 – 100)
Networks available
HMO,
Aetna Whole Health Banner Health Network HMO,
Aetna Whole Health Arizona Care Network HMO
Health Network Option (Open Access)
Member benefits*
Network care
Network care
Out-of-network care
$0/$0
$1,500/$3,000
$3,000/$6,000
$3,000/$6,000
$6,600/$13,200
$13,200/$26,400
Plan name
Embedded
Embedded
$25 copay
waived
$50 copay
waived
Walk-in clinics
$25 copay
waived
$50 copay
waived
$50 copay
waived
$250 copay
$500 copayment per day to a maximum of
$1,500 per admission
Outpatient surgery
$500 copay at ASC; $750 copay at hospital
at hospital
Emergency room
$250 copay
waived
Paid as In-Network
Urgent care
$60 copay
waived
PT/OT/ST combined.
$50 copay
Chiropractic
$50 copay
waived
Pharmacy**
Network
Network
Out of network
Pharmacy deductible
None
None
None
T1: $20 copay
T1: $15 copay
Not Covered
$50 copay
$50 copay
Not Covered
$80 copay
$80 copay
Not Covered
P: 30% up to $300; NP: 50% up to $500
P: 30% up to $300;
NP: 50% up to $500
Not Covered
31
M
Indemnity plan
Plan name
Silver Indemnity 1500 80% (2 – 50)
Indemnity 1500 80% (51 – 100)
Networks available
NA
Member benefits*
32
$1,500/$3,000
$6,600/$13,200
Embedded
Walk-in clinics
Outpatient surgery
Emergency room
Urgent care
PT/OT/ST combined.
Chiropractic
Pharmacy**
Network
Out of network
Pharmacy deductible
None
None
T1: $20 copay
T1: $20 copay
$50 copay
$50 copay
$80 copay
$80 copay
P: 30% up to $300; NP:
50% up to $500
P: 30% up to $300; NP:
50% up to $500
M
Footnotes
All services are subject to the deductible unless noted
otherwise. Some benefits are subject to age and frequency
schedules, limitations or visit maximums. Members or
providers may be required to precertify or obtain approval
for certain services.
1Embedded – No one family member may contribute more
than the individual deductible/out-of-pocket limit amount
to the family deductible/out-of-pocket limit. Once the
family deductible/out-of-pocket limit is met, all family
members will be considered as having met their deductible/
out-of-pocket limit for the remainder of the calendar year.
2Benefit limits are combined between network and
out-of-network care.
*We cover the cost of services based on whether doctors
are “in network” or “out of network.”
Members may choose a provider (doctor or hospital) in our
network. They may choose to visit an out-of-network
provider. If a member chooses a doctor who is out of
network, the Aetna health plan may pay some of that
doctor’s bill. Most of the time, members will pay a lot more
money out of pocket if they choose to use an out-ofnetwork doctor or hospital.
plans, members may be responsible for more than the
in-network cost sharing. The additional amounts could be
very large. Look at the plan or contact us to find out more
about how the plan pays for emergency services.
** If the physician prescribes or the member requests a
covered brand-name prescription drug when a generic
prescription drug equivalent is available, the member
will pay the difference in cost between the brand-name
prescription drug and the generic prescription drug
equivalent plus the applicable cost sharing. The cost
difference between the generic and brand does not
count toward the out-of-pocket limit.
***T1=Preferred generic drugs.
†Includes nonpreferred generic and brand drugs.
†† P=Preferred specialty drugs; NP=Nonpreferred
specialty drugs.
Note: For a summary list of limitations and exclusions, refer
to page 81. Please refer to our Producer World® web site
at www.aetna.com for specific Summary of Benefits
and Coverage documents. Or for more information, please
contact your licensed agent or Aetna Sales Representative.
When members choose out-of-network care, the plan
limits the amount it will pay. This limit is called the
“recognized” or “allowed” amount.
Professional Services: 90% of Medicare
Facility Services: 90% of Medicare.
Out-of-network doctors set their own rates. It may be
higher — sometimes much higher — than what the
Aetna plan “recognizes.” Out-of-network doctors may bill
for the dollar amount that the plan doesn’t “recognize.”
Members must also pay any copayments, coinsurance and
deductibles under the plan. No dollar amount above the
“recognized charge” counts toward the deductible or
out-of-pocket maximums. To learn more about how we
pay out-of-network benefits visit www.aetna.com. Type
“how Aetna pays” in the search box.
Members can avoid these extra costs by getting care
from our broad network of health care providers. Go to
www.aetna.com and click on “Find a doctor, dentist,
facility or vision provider.” Existing members may sign on
to their Aetna Navigator member site.
This applies when members choose to get care out of
network. When they have no choice (usually, for
emergency services), some of our plans pay the bill as if
they got care in network. For those plans, members pay
cost sharing and deductibles based on the in-network
level of benefits. Members do not have to pay anything
else. Other plans pay the bill differently. And, under those
33
Aetna dental plans
Dental coverage is sure to put a smile
on an employee’s face. Our affordable
plan design options make it possible
for you to add this valuable benefit to
your package.
34
D
Dental
overview
The Mouth MattersSM
PPO Max plan
Research suggests that serious gum disease, known as
periodontitis, may be associated with many health problems.
This is especially true if gum disease continues without
treatment.1 Now, here’s the good news. Researchers are
discovering that a healthy mouth may be important to your
overall health.1
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 PPO fee schedule,
rather than the usual and prevailing 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.
The Aetna Dental/Medical IntegrationSM program,* available
at no additional charge to plan sponsors that have both
medical and dental coverage 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 to visit the dentist. Once at the
dentist, these at-risk members will receive enhanced dental
benefits including an extra cleaning and full coverage for
certain periodontal services. Please see plan documents for
limitations and exclusions.
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 and will not
balance-bill members.
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 15th of the month to be
effective the following month.
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.
Aetna Dental Preventive CareSM plan
The Preventive Care plan is a lower cost dental plan that
covers preventive and diagnostic procedures. Members
pay nothing for these services when visiting an Aetna
PPO dentist.
1MayoClinic.com. “Oral health: A window to your overall health.” www.mayoclinic.com/health/dental/DE00001 [article online].
February 5, 2011. Accessed August 2013.
*DMI may not be available in all states.
**Dual Option does not apply to preventive plans or Voluntary Dental 3 – 9 size plans.
35
D
Aetna dental plans 2 – 9
Option 1
DMO
Option 2
Freedom-of-Choice —
Monthly selection between
the DMO and PPO Max
Option 3
PPO Max 1500
Option 4
PPO Max 1000
DMO Plan
100/80/50
DMO Plan 41
PPO Max Plan
100/70/40
PPO Max Plan
100/80/50
PPO Max Plan
100/80/50
Office visit copay
$5
$10
N/A
N/A
N/A
Annual deductible per member
(Does not apply to diagnostic and preventive services)
None
None
$50; 3X family
maximum
$50; 3X family
maximum
$50; 3X family
maximum
Annual maximum benefit
Unlimited
Unlimited
$1,000
$1,500
$1,000
100%
No charge
100%
100%
100%
Diagnostic services
Oral exams
Periodic oral exam
Comprehensive oral exam
100%
No charge
100%
100%
100%
Problem-focused oral exam
100%
No charge
100%
100%
100%
Bitewing – single film
100%
No charge
100%
100%
100%
Complete series
100%
No charge
100%
100%
100%
100%
No charge
100%
100%
100%
X-rays
Preventive services
Adult cleaning
Child cleaning
100%
No charge
100%
100%
100%
Sealants – per tooth
100%
$10
100%
100%
100%
Fluoride application – with cleaning
100%
No charge
100%
100%
100%
Space maintainers
100%
No charge
100%
100%
100%
Amalgam filling – 2 surfaces
80%
$32
70%
80%
80%
Resin filling – 2 surfaces, anterior
80%
$55
70%
80%
80%
Basic services
Oral surgery
Extraction – exposed root or erupted tooth
80%
$30
70%
80%
80%
Extraction of impacted tooth – soft tissue
80%
$80
70%
80%
80%
Complete upper denture
50%
$500
40%
50%
50%
Partial upper denture (resin base)
50%
$513
40%
50%
50%
Major services*
Crown – porcelain with noble metal1
50%
$488
40%
50%
50%
Pontic – porcelain with noble metal1
50%
$488
40%
50%
50%
Inlay – metallic (3 or more surfaces)
50%
$463
40%
50%
50%
50%
$175
40%
80%
50%
Bicuspid root canal therapy
80%
$195
40%
80%
50%
Molar root canal therapy
50%
$435
40%
80%
50%
Scaling & root planing – per quadrant
80%
$65
40%
80%
50%
Osseous surgery – per quadrant
50%
$445
40%
80%
50%
Not covered
Not covered
Not covered
Not covered
Not covered
Does not apply
Does not apply
Does not apply
Does not apply
Does not apply
Oral surgery
Removal of impacted tooth – partially bony
Endodontic services
Periodontic services
Orthodontic services
Orthodontic lifetime maximum
36
D
Aetna dental plans 2 – 9
Option 5
Option 6
PPO 1500 (90th) DMO Copay 41
Option 7
DMO Access
Option 8
Aetna Dental
Option 9
Preventive Care PPO Max 2000
PPO Plan
100/80/50
DMO Plan 41
DMO plan 42
(DMO Access)
PPO Max
100/0/0
PPO Max Plan
100/80/50
Office visit copay
N/A
$10
$10
N/A
N/A
$50; 3X family
maximum
None
None
None
$50; 3X family
maximum
$1,500
Unlimited
Unlimited
Unlimited
$2,000
Periodic oral exam
100%
No charge
No charge
100%
100%
100%
No charge
No charge
100%
100%
100%
No charge
No charge
100%
100%
100%
No charge
No charge
100%
100%
Complete series
100%
No charge
No charge
100%
100%
Adult cleaning
100%
No charge
No charge
100%
100%
Child cleaning
100%
No charge
No charge
100%
100%
100%
$10
$10
100%
100%
100%
No charge
No charge
100%
100%
Space maintainers
100%
$100
$100
100%
100%
80%
$32
$32
Not covered
80%
80%
$55
$55
Not covered
80%
80%
$30
$30
Not covered
80%
80%
$80
$80
Not covered
80%
50%
$500
$500
Not covered
50%
50%
$513
$513
Not covered
50%
50%
$488
$488
Not covered
50%
50%
$488
$488
Not covered
50%
50%
$463
$463
Not covered
50%
50%
$175
$175**
Not covered
80%
50%
$195
$195
Not covered
80%
50%
$435
$435**
Not covered
80%
50%
$65
$65
Not covered
80%
50%
$445
$445**
Not covered
80%
Not covered
Not covered
Not covered
Not covered
Not covered
Does not apply
Does not apply
Does not apply
Does not apply
Does not apply
Diagnostic services
Oral exams
X-rays
Preventive services
Basic services
Oral surgery
Major services*
Oral surgery
Endodontic services
37
D
Dental plans 2 – 9
Footnotes
*Coverage waiting period: Must be an enrolled member
of the plan for 12 months before becoming eligible for
coverage of any major service. Does not apply to the
DMO in plan options 1, 2, 6 and 7, and the Aetna Dental
Preventive Care in option 8.
**Specialist procedures are not covered by the plan when
performed by a participating specialist. However, the
service is available to the member at a discount.
Fixed dollar amounts on the DMO in plan options 1, 2, 6 and
7 are member responsibility
1There will be an additional patient charge for the actual cost
for gold/high noble metal for these procedures for the DMO
in plan options 2, 6 and 7.
Most oral surgery, endodontic and periodontic services are
covered as basic services on the DMO in options 1, 2, 6 and 7.
All oral surgery, endodontic and periodontic services are
covered as basic services on the PPO in plan options 3 and 9.
Plan options 2, 3, 4, 8 and 9; PPO Max nonpreferred
(out-of-network) coverage is limited to a maximum
of the plan’s payment, which is based on the contracted
maximum fee for participating providers in the particular
geographic area.
Out-of-network plan payments are limited by geographic
area on the PPO in plan option 5 to the prevailing fees at
the 90th percentile.
The DMO in plan option 1, 6 and 7 can be offered with any
one of the PPO plans in plan options 3 – 5 and 9 in a dual
option package.
DMO Access: Apart from the DMO network and DMO plan
of benefits, members under this plan also have access to
the Aetna Dental Access network. This network provides
access to providers who participate in the Aetna Dental
Access network and have agreed to charge a negotiated
discounted fee. Members can access this network for any
service. However, the DMO benefits do not apply in situations
where the dentist participates in both the Aetna Dental
Access network and the Aetna DMO network. DMO benefits
take precedence over all other discounts, including discounts
through the Aetna Dental Access network.
DMO frequency limitations will not apply to the following
services if needed more frequently due to medical necessity:
oral examinations, prophylaxis, fluoride treatments, bitewing
X-rays, entire series of panoramic X-rays.
Plan features and availability may vary by location and are
subject to change. Information is believed to be accurate as
of the production date; however, it is subject to change.
38
Above list of covered services is representative. Full list with
limitations as determined by Aetna appears on the plan
booklet/certificate. For a summary list of limitations and
exclusions, refer to page 82.
D
Voluntary Option 1
DMO
Voluntary Option 2
Freedom-of-Choice — Monthly selection
between the DMO and PPO Max Plan
Voluntary Option 3
PPO Max
DMO Plan 100/80/50
DMO Plan 100/90/60
PPO Max Plan 100/70/40
Office visit copay
$10
$10
N/A
N/A
None
None
$50; 3X family maximum
Unlimited
Unlimited
$1,000
$1,500
Periodic oral exam
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Complete series
100%
100%
100%
100%
Adult cleaning
100%
100%
100%
100%
Child cleaning
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Space maintainers
100%
100%
100%
100%
80%
90%
70%
80%
80%
90%
70%
80%
80%
90%
70%
80%
80%
90%
70%
80%
50%
60%
40%
50%
50%
60%
40%
50%
50%
60%
40%
50%
50%
60%
40%
50%
50%
60%
40%
50%
50%
60%
40%
50%
80%
90%
40%
50%
50%
60%
40%
50%
80%
90%
40%
50%
50%
60%
40%
50%
Not covered
Not covered
Not covered
Not covered
Does not apply
Does not apply
Does not apply
Does not apply
Diagnostic services
Oral exams
X-rays
Preventive services
Basic services
Oral surgery
Major services*
Oral surgery
Endodontic services
39
D
Option 4
DMO Copay 41
Option 5
DMO Access
Option 6
Aetna Dental Preventive Care
DMO Plan 41
DMO plan 42
PPO Max 100/0/0
Office visit copay
$15
$15
N/A
None
None
None
Unlimited
Unlimited
Unlimited
Diagnostic services
Oral exams
Periodic oral exam
No charge
No charge
100%
No charge
No charge
100%
No charge
No charge
100%
No charge
No charge
100%
Complete series
No charge
No charge
100%
Adult cleaning
No charge
No charge
100%
Child cleaning
No charge
No charge
100%
$10
$10
100%
No charge
No charge
100%
Space maintainers
$100
$100
100%
$32
$32
Not covered
$55
$55
Not covered
$30
$30
Not covered
$80
$80
Not covered
$500
$500
Not covered
$513
$513
Not covered
$488
$488
Not covered
$488
$488
Not covered
$463
$463
Not covered
$175
$175**
Not covered
$195
$195
Not covered
$435
$435**
Not covered
$65
$65
Not covered
$445
$445**
Not covered
Not covered
Not covered
Not covered
Does not apply
Does not apply
Does not apply
X-rays
Preventive services
Basic services
Oral surgery
Major services*
Oral surgery
Endodontic services
40
D
Footnotes
*Coverage waiting period: Must be an enrolled member
of the plan for 12 months before becoming eligible for
coverage of any major service. Does not apply to the
DMO in voluntary plan options 1, 2, 4 and 5 and on the
PPO in voluntary plan option 6.
**Specialist procedures are not covered by the plan when
performed by a participating specialist. However, the
service is available to the member at a discount.
Fixed dollar amounts on the DMO in voluntary plan options
1, 2, 4 and 5 are member responsibility
1There will be an additional patient charge for the actual cost
for gold/high noble metal for these procedures for the DMO
in voluntary plan options 4 and 5.
Most oral surgery, endodontic and periodontic services
are covered as basic services on the DMO in voluntary
options 1, 2, 4 and 5.
Plan options 2, 3 and 6; PPO Max non-preferred(out-ofnetwork) coverage is limited to a maximum of the plan’s
payment, which is based on the contracted maximum fee for
participating providers in the particular geographic area.
If there is a lapse in coverage, members may not re-enroll
in the plan for a period of two years from the date of
termination. If they are eligible for coverage at that time,
they may re-enroll, subject to all provisions of the plan,
including, but not limited to, the coverage waiting period.
DMO Access: Apart from the DMO network and DMO plan
of benefits, members under this plan also have access to
the Aetna Dental Access network. This network provides
access to providers who participate in the Aetna Dental
Access network and have agreed to charge a negotiated
discounted fee. Members can access this network for any
service. However, the DMO benefits do not apply. In situations
where the dentist participates in both the Aetna Dental
Access network and the Aetna DMO network, DMO benefits
take precedence over all other discounts including discounts
through the Aetna Dental Access network.
oral examinations, prophylaxis, fluoride treatments,
bitewing X-rays, entire series of panoramic X-rays.
41
D
Standard and voluntary dental plan selections 10 – 100
Option 1A
DMO 100/80/50
Option 2A FOC PPO Max
Monthly selection between the DMO and PPO Max
DMO Plan 100/80/50
100/90/60
Office visit copay
$5
$5
N/A
None
None
Unlimited
Unlimited
$1,000
Diagnostic services
Oral exams
Periodic oral exam
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Complete series
100%
100%
100%
100%
100%
100%
X-rays
Preventive services
Adult cleaning
Child cleaning
100%
100%
100%
100%
100%
100%
100%
100%
100%
Space maintainers
100%
100%
100%
Basic services
80%
90%
80%
80%
90%
80%
80%
90%
80%
80%
90%
80%
Endodontic services
Oral surgery
80%
90%
80%
80%
90%
80%
50%
60%
50%
50%
60%
50%
Major services*
Crown – porcelain with noble metal
50%
60%
50%
Pontic – porcelain with noble metal
50%
60%
50%
50%
60%
50%
50%
60%
50%
50%
60%
50%
50%
60%
50%
$2,300 copay
$2,300 copay
50%
Does not apply
Does not apply
$1,000
Oral surgery
Endodontic services
Orthodontic services*
(optional for dependent children)
42
D
Option 3A FOC PPO 80th
Option 4A
Monthly selection between the DMO and PPO PPO Max 1000
Option 5A
PPO Max 1500
100/90/60
PPO Plan 100/80/50
Office visit copay
$5
N/A
N/A
N/A
None
Unlimited
$1,000
$1,000
$1,500
Periodic oral exam
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Complete series
100%
100%
100%
100%
Adult cleaning
100%
100%
100%
100%
Child cleaning
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Space maintainers
100%
100%
100%
100%
90%
80%
80%
80%
90%
80%
80%
80%
90%
80%
80%
80%
90%
80%
80%
80%
90%
80%
80%
80%
90%
80%
80%
80%
60%
50%
50%
50%
60%
50%
50%
50%
60%
50%
50%
50%
60%
50%
50%
50%
60%
50%
50%
50%
60%
50%
80%
80%
60%
50%
80%
80%
60%
50%
80%
80%
$2,300 copay
50%
50%
50%
Does not apply
$1,000
$1,000
$1,000
Diagnostic services
Oral exams
X-rays
Preventive services
Basic services
Endodontic services
Oral surgery
Major services*
Oral surgery
Endodontic services
43
D
Option 6A
PPO Max 2000
Option 7A
PPO 1000 80th
Option 8A
PPO 1500 90th
Option 9A
PPO 2000 90th
PPO Plan 100/80/50
PPO Plan 100/80/50
PPO Plan 100/80/50
Office visit copay
N/A
N/A
N/A
N/A
$2,000
$1,000
$1,500
$2,000
Periodic oral exam
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Complete series
100%
100%
100%
100%
Adult cleaning
100%
100%
100%
100%
Child cleaning
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Space maintainers
100%
100%
100%
100%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
50%
50%
50%
50%
$1,000
$1,000
$1,000
$1,000
Diagnostic services
Oral exams
X-rays
Preventive services
Basic services
Endodontic services
Oral surgery
Major services*
Oral surgery
Endodontic services
44
D
Footnotes
Voluntary plan options
Standard and voluntary plan options
*Coverage waiting period applies to voluntary PPO and
PPO Max options: Must be an enrolled member of the plan
for 12 months before becoming eligible for coverage of any
major service including orthodontic services. Does not
apply to the DMO in voluntary plan options 1A – 3A and
does not apply to standard plans.
Fixed dollar amounts on the DMO in plan options 1A – 3A are
member responsibility.
Voluntary plans: If there is a lapse in coverage, members may
not re-enroll in the plan for a period of two years from the
date of termination. If they are eligible for coverage at that
time, they may re-enroll, subject to all provisions of the plan,
including, but not limited to, the coverage waiting period.
Most oral surgery, endodontic and periodontic services are
covered as basic services in options 1A – 3A. All oral surgery,
endodontic and periodontic services are covered as basic
services on the PPO in plan options 4A, 5A and 7A. General
anesthesia along with all oral surgery, endodontic and
periodontic services are covered as basic services on the
PPO in plan options 6A, 8A and 9A.
Plan options 2A, 4A – 6A; PPO Max nonpreferred
(out-of-network) coverage is limited to a maximum
of the plan’s payment, which is based on the contracted
maximum fee for participating providers in the particular
geographic area.
Out-of-network plan payments are limited by geographic
area on the PPO in plan options 3A and 7A to the prevailing
fees at the 80th percentile and plan options 8A and 9A at the
90th percentile.
The DMO in plan option 1A can be offered with any
one of the PPO plans in plan options 4A – 7A in a dual
option package.
Coverage for implants is included as a major service on the
PPO in plan options 6A and 9A.
Orthodontic coverage is available only for dependent
children only.
oral examinations, prophylaxis, fluoride treatments, bitewing
X-rays, entire series or panoramic X-rays.
45
Aetna vision plans
Value you can see — our Premier,
Plus and Basic Aetna VisionSM Preferred
plans were designed to provide
affordable premiums, network choice
and low member out of pocket expense.
46
V
Vision
overview
See why Aetna Vision Preferred is the right choice
for you and your employees
Discover the freedom to see any licensed vision
office or retailer
•Members can go where they want and buy what they
want — in- and out-of-network benefits included for
most services.
•Offer as a voluntary benefit with affordable premiums and
no extra cost to your bottom line.
•Tax advantages for both you and your employees.
•Four-year rate guarantee included.
•Administrative ease when you have multiple benefits
with Aetna – one bill, one renewal, one trusted company
to work with!
•Award-winning live customer service and self-service tools
available seven days a week.
•Low member out of-pocket expense.
•Value, choice, and convenience. Members can choose any
frame available includes value-priced frames to
high-quality designer frames with no confusing frame
towers or formularies.
•Discounts on additional eyeglass purchases and noncovered
items including LASIK.*
•Informational welcome packet is sent to each enrolled
subscriber and includes member ID card, benefit summary
and nearest provider locations to the member’s home
ZIP Code.
Nearly 60 percent of eyewear dollars in the United States are
spent at optical retailers.2 With Aetna Vision Preferred, you and
your employees will have access to thousands of independent
providers and the most desired retail locations nationwide.
We have one of the largest national networks with over 65,000
vision office and retailers, including five of the most desired
national retailers,3 Including LensCrafters®, Pearle Vision®,
Sears® Optical , Target Optical® and JCPenney Optical. Most
with evening and weekend hours, including Sundays and
located in or near shopping centers for added convenience.
Can’t find your provider in our network? No problem. We
reimburse for most out-of-network services, so you are
covered no matter who you see for your routine eye care.
Low member out-of-pocket costs
Aetna Vision Preferred offers savings in or out of network for
routine eye exams, contact lenses and eyeglasses, including
prescription sunglasses and designer frames.
Sample out-of-pocket costs
for a member**
Retail price
Out-ofpocket costs
with Aetna
Vision
Preferred
Savings with
Aetna Vision
Preferred
Exam
$114.00
$10.00
$104.00
Frames
$124.41
$0
$124.41
Lenses
$ 83.00
$10.00
$ 73.00
Total
$321.41
$20.00
$301.41
Keep an eye on your employee’s health
We are committed to vision wellness, patient education and
the associated preventive care.
Encouraging employees to get vision care can help lower
unnecessary costs and improve overall health. During a
routine eye exam, all aspects of vision are checked, including
the eye’s structure and how well the eyes work together.
Annual eye exams allow eye care providers to monitor the
health of the eyes and track changes that can occur from year
to year. Besides measuring vision, eye exams help find early
signs of certain chronic health conditions including high
blood pressure, high cholesterol or other problems.1
*Discounts may not be available in all states.
**Results will vary for different plan designs. Example does not include premiums.
1Allaboutvision.com/eye-exam/importance.htm, April 2012. Accessed September 2014.
2Jobson Vision Watch, Vision Council Member Benefits Report, June 2011.
3Jobson Consumer Perceptions of Managed Vision Care Report 2011.
Refer to page 83 for a list of limitations and exclusions.
47
V
Aetna Vision Preferred – Premier plan
In network
Out of network
In-network amount represents member copay, plan allowance or fixed discounted fee.
Out-of-network amount represents the maximum reimbursement amount.
Exam – coverage allowed for one eye exam every rolling 12 months
Routine eye exam
$10 copay
$25 Reimbursement
Standard contact lens fit/follow
$40 discounted fee
Not covered
Premium contact lens fit/follow
10% off retail
Not covered
Frames – coverage allowed for one eyeglass frame every rolling 12 or 24 months (rates vary by frame frequency)
Any frame available at location
$130 plan allowance
$65 reimbursement
Lens – coverage allowed for one pair of prescription eyeglass lenses every rolling 12 months (in lieu of contact lenses per benefit period)
Single vision lenses
$10 copay
$20 reimbursement
Bifocal vision lenses
$10 copay
$40 reimbursement
Trifocal vision lenses
$10 copay
$65 reimbursement
Lenticular vision lenses
$10 copay
$65 reimbursement
Standard progressive lenses
$75 copay
$40 reimbursement
Premium progressive lenses
20% discount off retail minus $120 allowance
plus $75 copay = member out of pocket
$40 reimbursement
UV treatment
$15 discounted fee
Not covered
Tint (solid and gradient)
$15 discounted fee
Not covered
Standard plastic scratch coating
$15 discounted fee
Not covered
Standard Polycarbonate lenses – child to age 19
$40 discounted fee
Not covered
Standard Polycarbonate lenses – adult
$40 discounted fee
Not covered
Standard anti-reflective coating
$45 discounted fee
Not covered
Contacts – coverage for 1 order of contact lenses every rolling 12 months (in lieu of eyeglass lenses per benefit period)
Conventional contact lenses
$115 plan allowance
$80 reimbursement
Disposable contact lenses
$115 plan allowance
$80 reimbursement
Medically necessary contact lenses
$0 copay
$200 reimbursement
Discounts
Available at in-network locations
•15 percent off balance over the plan allowance on conventional contact lenses
•20 percent off balance over the plan allowance on frames
•Up to 40 percent off additional pairs of eyeglasses or prescription sunglasses
•15 percent discount off retail or 5 percent discount off the promotional price for LASIK
Laser vision correction or PRK from U.S. Laser Network only. Call 1-800-422-6600
•20 percent off noncovered items, including photochromic/transition and polarized lenses
•Receive significant savings after your lens benefit has been exhausted by ordering
replacement contact lenses online at www.aetnavision.com
48
Discounts may not be available in all states.
V
Aetna Vision Preferred – Plus plan
In network
Out of network
Routine eye exam
$10 copay
$25 reimbursement
$40 discounted fee
Not covered
10% off retail
Not covered
$130 plan allowance
$65 reimbursement
$25 copay
$10 reimbursement
$25 copay
$25 reimbursement
$25 copay
$55 reimbursement
$25 copay
$55 reimbursement
$90 copay
$25 reimbursement
$25 reimbursement
UV treatment
$15 discounted fee
Not covered
$15 discounted fee
Not covered
$0 copay
$15 reimbursement
$0 copay
$35 reimbursement
$40 discounted fee
Not covered
$45 discounted fee
Not covered
$130 plan allowance
$90 reimbursement
$130 plan allowance
$90 reimbursement
$0 Copay
$200 reimbursement
Discounts
•20 percent off non-covered items, including photochromic/transition and polarized lenses
49
V
Aetna Vision Preferred – Basic plan
In network
Out of network
Routine eye exam
$20 copay
$20 reimbursement
$40 discounted fee
Not covered
10% off retail
Not covered
$100 plan allowance
$50
$20 copay
$15 reimbursement
$20 copay
$30 reimbursement
$20 copay
$60 reimbursement
$20 copay
$60 reimbursement
$85 copay
$30 reimbursement
$30 reimbursement
UV treatment
$15 discounted fee
Not covered
$15 discounted fee
Not covered
$15 discounted fee
Not covered
$40 discounted fee
Not covered
$40 discounted fee
Not covered
$45 discounted fee
Not covered
$105 plan allowance
$75 reimbursement
$105 plan allowance
$75 reimbursement
$0 copay
$200 reimbursement
Discounts
•20 percent off non-covered items, including photochromic/transition and polarized lenses
50
Aetna life & disability
With Aetna as your insurer, you can
round out employee benefits package
with even more coverage. Our group
life and disability is an affordable way
to offer your employees — and their
families — the extra financial protection
of life insurance and disability benefits.
51
L&D
Life & disability
overview
For groups of 2 to 50, Aetna Life Insurance Company (Aetna)
Small Group packaged life and disability insurance plans
include a range of flat-dollar insurance options bundled
together in one monthly per-employee rate. These products
are easy to understand and offer affordable benefits to help
your employees protect their families in the event of illness,
injury or death.
You’ll benefit from streamlined plan installation, administration
and claims processing, and all of the benefits of our standalone
life and disability products for small groups. Or, simply choose
from our portfolio of group basic term life and disability
insurance plans.
For groups of 51 and above, we offer a robust portfolio of
life and disability product with flexible plan features. Please
consult your sales representative for a plan designed to meet
your group’s needs:
•Basic life
•Supplemental life
•AD&D Ultra®
•Supplemental AD&D Ultra®
•Dependent life
•Short-term disability
•Long-term disability
Life insurance
We know that life insurance is an important part of the
benefits package you offer your employees. That’s why our
products and programs are designed to meet your needs for:
•Flexibility
•Added value
•Cost efficiency
•Experienced support
We help you give employees what they’re looking for
in lifestyle protection, through our selected group life
insurance options. And we look beyond the benefits
payout to include useful enhancements through the
Aetna Life EssentialsSM program.
So what’s the bottom line? A portfolio of value-packed
products and programs to attract and retain workers —
while making the most of the benefits dollars you spend.
Giving you (and your employees) what you want
Employees are looking for cost-efficient plan features and
value-added programs that help them make better decisions
for themselves and their dependents.
Our life insurance plans come with a variety of
features including:
Accelerated death benefit – Also called the “living
benefit,” the accelerated death benefit provides payment to
terminally ill employees or spouses. This payment can be up
to 75 percent of the life insurance benefit.
Premium waiver provision – Employee coverage may stay in
effect up to the amended normal social security retirement
age without premium payments (unless they retire sooner),
if an employee becomes permanently and totally disabled
while insured due to an illness or injury before age 60.
Optional dependent life – This feature allows employees
to add optional additional coverage for eligible spouses
and children for employers with 10 or more employees.
This employee-paid benefit enables employees to cover
their spouses and dependent children.
Our fresh approach to life
With Aetna Life Essentials, your employees have access to
programs during their active lives to help promote healthy,
fulfilling lifestyles. In addition, Aetna Life Essentials provides
for critical caring and support resources for often-overlooked
needs during the end of one’s life. And we also include value
for beneficiaries and their loved ones well beyond the
financial support from a death benefit.
52
L&D
AD&D Ultra®
We understand disability
AD&D Ultra is standardly included with our small group
term life plans and in our packaged life and disability plans,
and provides employees and their families with the same
coverage as a typical accidental death and personal loss
plan — and then some. This includes extra benefits at no
additional cost to you, such as coverage for education or
child-care expenses that make this protection even
more valuable.
We have experienced and caring professionals who
understand the challenges of disability. We realize how
important it is for your employees to be able to work.
Covered losses include:
•Death
•Loss of limb
•Loss of sight
•Loss of speech
•Loss of hearing
•Third-degree burns
•Paralysis
•Coma
•Total disability
•Exposure and disappearance
Extra benefits for the following:
•Passenger restraint use and airbag deployment*
•Education assistance for dependent child and/or spouse*
•Child care*
•Repatriation of mortal remains*
Disability insurance
Did you know the ability to earn an income is the most
important financial resource for an individual? Yet, few
take steps to help protect this important resource from
the threat of a disability.
No one wants to think about it, but injury or illness can
happen at any time. It can impact both your business and
your employees’ financial well-being. Your business can lose
the productivity of valued employees. Your employees can
lose their paycheck.
Here are a few ways our disability plans protect you and
your employees:
•Consultative support from your account team is based
on the unique needs of your business
•Our embedded Behavioral Health Unit (BHU) has
compassionate licensed therapists and psychiatric
nurses who recognize the complexities of behavioral
health conditions. They work with your employees
and their health care providers to overcome barriers
blocking successful return to work
•Master’s level Vocational Rehabilitation Consultants
offer a coordinated productivity approach centered on
the employee’s abilities to aid your employee’s transition
back to the workforce
We try to make it easy
We integrate with your other Aetna benefit plans to make
it easier for you and your employees. If consent is required
to be compliant with HIPAA regulations, your employees
can provide that consent online or by phone. This can
expedite the sharing of information across products to
simplify the claim experience. Integration also allows your
account team to provide you with reports that combine
your benefit plans data results.
Our best-in-class technology offers more choices for you
and your employees to interact with us. Whether you choose
mail, phone, e-mail, mobile application or our convenient
WorkAbility® Absence Management System online portal,
information is available on your schedule, not ours.
For a summary list of limitations and exclusions, refer to
page 81 – 83
That is why disability insurance is so important. It provides
protection for your business and your employees.
*Only available if insured loses life.
Life insurance policies and disability insurance plans/policies are offered and/or underwritten by Aetna Life Insurance
Company (Aetna).
53
L&D
Life plan options
54
Life benefits
2 – 9 lives
10 – 50 lives
51 – 100 lives
Benefit amount
$10,000, $15,000, $20,000 or $50,000
flat dollar amount
$10,000, $15,000, $20,000,$25,000,
$30,000, $50,000, $75,000, $100,000,
$125,000, $150,000, $175,000,
$200,000 flat dollar amounts
OR
1 or 2X BAE
(rounded to next higher $1,000)
$10,000 to $300,000
($10,000 or $25,000 increments)
OR
1, 1.5 or 2X BAE
(rounded to next higher $1,000)
Minimum/Maximum amounts
$10,000/$50,000
$10,000/$200,000
$10,000/$300,000
Guaranteed issue
$20,000
$200,000
Flat dollar $300,000;
Salary $500,000
Participation requirement
100%
100% employer pays all,
50% employee contributes
100% employer pays all,
75% employee contributes
Contribution requirement
100% employer paid
50% – 100% Employer Paid
50% – 100% Employer Paid
Eligible/Minimum hours
Active employees/20 hrs./wk.
Rate structure
Non-contributory: Composite
Contributory: Age Graded
Non-contributory: Composite
Composite
Rate guarantee
2 years
2 years
2-3 years
Age reduction schedule
65% at age 65, 40% at age 70, 25% at
age 75
Option 1: 65% at age 65, 40% at age 70,
25% at age 75
25% at age 80
Option 3: 50% at age 70
Option 4: 65% at age 65, 50% at age 70
25% at age 75
25% at age 80
Option 3: 50% at age 70
Option 4: 65% at age 65, 50% at age 70
Option 5: Match current plan
Waiver of premium
Premium waiver 60
Premium waiver 60
Premium waiver 60
Funding
Prospective
Prospective
Prospective
Conversion
Included
Included
Included
Portability
Not included
Not included
Available per state filing
Value added services
Aetna Life Essentials
Beneficiary Solutions
Everest Funeral Services
Accelerated death benefit
Up to 75% of Life benefit
Up to 75% of Life benefit amount
Up to 75% of Life benefit amount
AD&D Ultra amount
Matches Life benefit amount
Optional spouse life
Not available
Flat $25,000
Increments of $10,000 to a maximum of
$100,000 (not to exceed 100% of EE
Supplemental Amount)
Optional child life
Not available
Flat $10,000 birth to age 26
Increments of $2,000 to $10,000 to a
maximum of $10,000
Spouse/Child life rate structure
N/A
Spouse: Per $1,000 – Age Graded;
Child: Per $1,000
Per Family Unit
Spouse: Per $1,000 – Age Graded
Child: Composite Rate
Spouse/Child life guarantee issue
N/A
Spouse: $25,000
Child: $10,000
Spouse: $30,000
Child: $10,000
Spouse/Child AD&D
Not available
Spouse: 50% employee amount
(40% if Child included)
Child: 15% employee amount
(10% if Spouse included)
Spouse: 50% employee amount
(40% if Child included)
Child: 15% employee amount
(10% if Spouse included)
Supplemental life
Not available
Up to $400,000
(increments $10,000 or $25,000)
OR
1 – 5 X BAE rounded to next $1000
Up to $500,000
(increments $10,000 or $25,000)
OR
1 – 5 X BAE rounded to next $1000
Supplemental AD&D
Not available
Matches Supplemental Life Benefit;
Automatically included in Supplemental
Life Rate
Matches Supplemental Life Benefit;
Automatically included in Supplemental
Life Rate
Class schedules
Only one class allowed
Up to 3 classes
(minimum 3 employees in each class)
Up to 3 classes
(minimum 3 employees in each class)
Life and disability products are underwritten or administered by Aetna Life Insurance Company (Aetna).
L&D
Disability plan options – short term
Short term benefits
Plan amount
2 – 9 lives*
$100 – $500 flat amount in
$100 increments
10 – 50 lives*
50% or 60% of earnings
51 – 100 lives**
50%, 60% or 66 ⅔% of earnings
Benefits start-injury/illness
1/8 or 8/8
1/8, 8/8 or 15/15
1/8, 8/8, 15/15, 30/30
Maximum benefit
$500
$500, $750, $1000, $1500 or $2000
To a maximum of $2,000 must qualify
based on average of top 3 Salaries
Maximum benefit period
26 weeks
13 weeks or 26 weeks
9 weeks, 11 weeks, 13 weeks, 26 weeks
OR
52 weeks
Maternity benefit
Maternity is treated same as illness
but subject to preexisting condition
exclusion. If pregnant before plan
effective date, pregnancy is not
covered unless employee has prior
credible coverage
Type of disability covered
Non-occupational
Non-occupational
Non-occupational
Pre-existing condition rule
12-Mar
3/12 for late applicants and voluntary
plans
3/12 for late applicants and voluntary
plans
Actively-at-work rule
Applies
Applies
Applies
Other income offset integration
None
Full offsets, including family SSDI
Definition of disability
Own occupation, 20% earnings loss
Own occupation, 20% earnings loss
Own occupation 20% earnings loss
Separate periods of disability
15 days
15 days
15 days
Funding
Prospective
Prospective
Prospective
100%
Contributory: 50%
Non-contributory: 100%
Voluntary (100% employee paid): 25% or
20 lives
100% Employer Paid: 100%
100% employer paid
Contributory: 50% – 99% employer paid
Non-contributory: 100% employer paid
Voluntary: 100% employee paid
Rate structure
Composite
Age graded rates
Voluntary: Age graded rates (60%
participation will receive composite rate)
Non-contributory: Composite rate
Rate guarantee
2 years
2 years
2 years
Class schedules
Only one class allowed
Up to 3 classes (with a minimum
requirement of 3 employees in each
class) available for groups of 10 or
more employees
Up to 3 classes (with a minimum
requirement of 3 employees in each
class) available for groups of 10 or
more employees
*For 2 to 50 lives: Short Term Disability is not available in CA, NJ, NY, HI or RI. These states have mandated state cash disability plans.
**For 51 to 100 lives, in states with mandated state cash disability plans, the STD plan will either supplement the state cash plan or
the state case plan will be an offset to the STD plan. CA, HI, NJ, NY and RI have mandated state cash disability plans.
55
L&D
Disability plan options – long term
Long term benefits
10 – 50 lives
51 – 100 lives
Plan amount
50% or 60% of earnings
50%, 60% or 66 ⅔% of earnings
Benefits Start-illness and injury
30 days, 90 days or 180 days
90 days or 180 days
Maximum benefit
$2000, $3500, $5000, $6000 or $8000
Up to $10,000
(must qualify based on average of top 3 Salaries)
Maximum benefit period
2 years or 5 years
2 years, 5 years or 1983 Amended SSNRA
Maternity benefit
Type of disability covered
Occupational and non-occupational
Occupational and non-occupational
Pre-existing condition rule
3/12 for new coverage and increases in coverage
3/12 for new coverage and increases in coverage
Actively-at-work rule
Applies
Applies
Other income offset integration
Own occupation for 24 months 80%;
After 24 months, any reasonable occupation 60%
Own occupation for 24 months 80%;
After 24 months, any reasonable occupation 60%
30 day EP: 15 days during EP, 3 months after
Work incentive benefit
adjustment
Proportional loss after 12 months
Proportional loss after 12 months
Limitations – mental/
Nervous and drug/Alcohol
24 months of benefits per disability;
90 day extension if hospital confined
24 months of benefits per disability;
90 day extension if hospital confined
Waiver of premium
Included
Included
Vocational rehabilitation
Mandatory except where prohibited by state law*;
Mandatory except where prohibited by state law*;
And incentive
10%
10%
Survivor benefit
Included – 3 months
Included – 3 months
Conversion
Not included
Not included
Funding
Prospective
Prospective
Contributory: 50%
Voluntary: Greater of 25% or 20 lives
Contributory: 50% - 99% employer paid
Voluntary: 100% employee paid
Rate structure
Age graded rates
Voluntary: Age graded rates
(60% participation will receive composite rate)
Non contributory:
51 – 100 lives: Composite rate
56
Rate guarantee
2 years
2 – 3 years
Class schedules
Up to 3 classes (with a minimum requirement
of 3 employees in each class) available for groups
of 10 or more employees
Up to 3 classes (with a minimum requirement
of 3 employees in each class) available for groups
of 10 or more employees
*Mandatory Vocational Rehabilitation is prohibited in CA and NJ. CT prohibits mandatory Vocational Rehabilitation if the plan is
contributory or voluntary.
L&D
Packaged life and disability plan options
Plan options 2 – 50
Basic life plan design
Low option
Low option 2
Medium option
Medium option 2
High option
Benefit
Flat $10,000
Flat $15,000
Flat $20,000
Flat $25,000
Flat $50,000
Guaranteed Issue
2 – 9 lives
10 – 50 lives
$10,000
$10,000
$15,000
$15,000
$20,000
$20,000
$20,000
$25,000
$20,000
$50,000
Reduction schedule
Employee’s original
life amount reduces
to 65% at age 65;
40% at age 70;
25% at age 75
life amount reduces
to 65% at age 65;
40% at age 70;
25% at age 75
life amount reduces
to 65% at age 65;
40% at age 70;
25% at age 75
life amount reduces
to 65% at age 65;
40% at age 70;
25% at age 75
life amount reduces
to 65% at age 65;
40% at age 70;
25% at age 75
Disability provision
Premium Waiver 60
Premium Waiver 60
Premium Waiver 60
Premium Waiver 60
Premium Waiver 60
Conversion
Included
Included
Included
Included
Included
Accelerated death benefit
Up to 75% of benefit;
24-month acceleration
Dependent life
Spouse $5,000;
Child $2,000
Spouse $5,000;
Child $2,000
Spouse $5,000;
Child $2,000
Spouse $5,000;
Child $2,000
Spouse $5,000;
Child $2,000
Matches basic life
benefit
Matches basic life
benefit
Matches basic life
benefit
Matches basic life
benefit
Matches basic life
benefit
AD&D Ultra
AD&D Ultra schedule
AD&D Ultra extra benefits
Passenger restraint use and airbag deployment, education benefit for your child
and/or spouse, child care and repatriation of mortal remains
Disability plan design
Monthly benefit
Flat $500;
No offsets
Flat $1,000; offsets are workers’ compensation, any state disability plan,
and primary and family social security benefits
Elimination period
30 days
30 days
30 days
30 days
30 days
Own occupation:
Earnings loss of 20%
or more
Own occupation:
or more
Own occupation:
or more
Own occupation:
or more
First 24 months
of benefits:
Own occupation:
or more; any reasonable
occupation thereafter:
40% earnings loss
Benefit duration
24 months
24 months
24 months
24 months
60 months
Pre-existing condition
limitation
3/12
3/12
3/12
3/12
3/12
Types of disability
Occupational &
non-occupational
Occupational &
non-occupational
Occupational &
non-occupational
Occupational &
non-occupational
Occupational &
non-occupational
15 days during
elimination period
6 months thereafter
15 days during
elimination period
6 months thereafter
15 days during
elimination period
6 months thereafter
15 days during
elimination period
6 months thereafter
15 days during
elimination period
6 months thereafter
Mental health/
Substance Abuse
Duration same as all
other conditions
other conditions
other conditions
other conditions
other conditions
Waiver of premium
Included
Included
Included
Included
Included
Active full-time
employees
Active full-time
employees
Active full-time
employees
Active full-time
employees
Active full-time
employees
Other plan provisions
Eligibility
Rate guarantee
1 year
1 year
1 year
1 year
1 year
Rates PEPM
$8.00
$10.00
$15.00
$16.00
$27.00
57
In business, nothing is more critical
to success than the health and
well-being of employees.
58
U
This material is for informational purposes only and is not intended to be all inclusive. Other policies and guidelines
may apply.
Note: State and Federal Legislation/Regulations, including Small Group Reform and ACA, take precedence over any and all
underwriting rules. Exceptions to underwriting rules require approval of the Director of Underwriting except where Executive
Director of Underwriting approval is indicated. This information is the property of Aetna and its affiliates (“Aetna”), and may only
be used or transmitted with respect to Aetna products and procedures, as specifically authorized by Aetna, in writing.
All underwriting guidelines below are subject to change without notice.
Affiliated,
Associated
or Multiple
Companies
•Employers who have more than one business with different tax identification numbers (TINs) may
be eligible to enroll as one group if the following are met:
--One owner has controlling interest of all business to be included; or
--The owner files (or is eligible to file) an Affiliations Schedule, IRS Form 851, a combined tax return
for all companies to be included. If they are eligible but choose not to file Form 851, please
indicate as such. A copy of the latest filed tax return must be provided; and
--All businesses filed under one combined tax return will be considered a single group. For example,
if the employer has three businesses and files all three under one combined tax return, then all
three businesses must be enrolled for coverage. If the request is for only two of the three
businesses to be enrolled, the group will be considered a carve out.
•The enrolling business (the group that is being used as the policy name) as well as the other
businesses to be combined must have the minimum number of employees required by the state
•51 to 100 eligible employees – the two or more groups may have multiple Standard Industrial
Classification (SIC) Codes; however, rates will be based on the SIC Code for the group with the
majority of employees, or the highest SIC rate if equal numbers.
•Employers must submit a completed Common Ownership form.
•Businesses with equal controlling interest may be considered, if the owners of the company
designate an individual to act on behalf of all the groups.
•Underwriting reserves the right to final underwriting review, and may consider common ownership
on a case-by-case basis.
Example
One owner has controlling interest of all companies to be included:
Company 1 – Jim owns 75% and Jack owns 25%
Company 2 – Jim owns 55% and Jack owns 45%
Both companies can be written as one group since Jim has controlling interest in both.
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Benefit Waiting
Period (BWP)
•BWPs must be consistently applied to all employees, including newly hired key employees.
•The BWP for future employees may be the 1st or 15th of the month following 0 days, 30 days or 60 days.
•One or two BWPs may be selected and must be consistently applied within a class of employees as
defined by the employer. If two classes are elected, each class must represent a distinct group of
employees (hourly vs. salaried, management vs. nonmanagement, etc.)
•Date of hire BWP is not available.
•You may request to waive the BWP at initial submission of the group and must apply this consistently
for all employees. To do so, check the box on the Employer Application form in the Benefit Waiting
Period section.
•Changes to the BWP can only occur one time in 12 months or on the group’s anniversary date.
•No retroactive BWP changes will be allowed.
•For new hires, the eligibility date will be the first day of the policy month following the waiting
period. Policy month refers to the contract effective date of the 1st or 15th.
--If “0” days is selected and the employee is hired on the 1st of the month, the effective date will be
the date of hire.
1st of the month
following the BWP
15th of the month
following the BWP
0 days
Date of hire: 4/1
Effective date: 4/1
Date of hire: 4/1
Effective date: 4/15
0 days
Date of hire: 4/18
Effective date: 5/1
Date of hire: 4/18
30 days
Date of hire: 4/18
Effective date: 6/1
Date of hire: 4/18
60 days
Date of hire: 4/18
Effective date: 7/1
Date of hire: 4/18
Examples
Carve Outs
Medical
•2 to 50 full-time eligible employees – allowed.
•51 to 100 full-time eligible employees – allowed, but must meet the standard participation
percentage for employees that fit the eligible definition regardless of class, or additional
factors are applied.
Dental, life and packaged life & disability
•Union employees if packaged with medical.
Case Submission
Dates
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•All new business case submissions must be received by Aetna Underwriting no later than the end
of the business day following the requested effective date.
•If not received by this date, the effective date will be moved to the next available effective date,
with potential rate impact.
•Any cases received after the cutoff date will be considered on an exception basis only, as approved
by the Underwriting Unit Manager.
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Census Data
•Census data must be provided for all eligible employees, including enrolled, waivers, employees in
the waiting period and COBRA eligible employees.
•Include the name, date of birth, date of hire, gender, dependent status, residence ZIP Code and
employee work location ZIP Code.
•2 to 50 eligible employees – also provide date of birth for each employee, spouse and child.
•If both husband and wife work for the same company, they may enroll together or separately.
•COBRA eligible employees should be included on the census and noted as COBRA.
•Rates are based on final enrollment.
Retirees
•2 to 50 eligible employees – not eligible.
•51 to 100 eligible employees:
--Medical – retirees are eligible.
--Dental – retirees cannot comprise more than 10% of the group.
--Provide census for retirees, split by over and under age 65.
--Retirees are not eligible for life, disability or voluntary dental.
--Retirees are not included in the count to determine the group size.
COBRA
•COBRA coverage will be extended in accordance with federal legislation/regulations.
•Employers with 20 or more employees (full and part time) are eligible to offer COBRA coverage.
•COBRA applies to group health plans sponsored by employers with 20 or more employees on more
than 50% of its typical business days in the previous calendar year.
--Include: full-time, part-time, seasonal, temporary, union, owners, partners, officers
--Exclude: self-employed persons, independent contractors (1099), directors
--Each part-time employee counts as a fraction of an employee, with the fraction equal to the
number of hours that the part-time employee worked divided by the hours an employee must
work to be considered full time
•Because COBRA is directed at employers, the employer must decide whether to comply with COBRA.
In situations where it may appear you are not subject to COBRA, for example a three-life group
requesting COBRA, we will ask you to “validate” the number of employees in the prior calendar year in
order to determine the number of employees for COBRA purposes.
•Life, disability and/or voluntary dental – COBRA enrollees are not eligible.
•Include eligible enrollees on the census.
•Provide the qualifying event, length, start date and end date.
•COBRA is not billed separately and is included with the group bill.
•If the COBRA enrollee does not reside in an Aetna service area, they are only eligible for out of
network benefits if applicable; or Urgent/Emergency care.
•Do not include COBRA enrollees in your employee count to determine the size of the group.
Once you have determined your group size according to the law applicable to the group, then
you can include COBRA enrollees for coverage subject to normal underwriting guidelines.
51 to 100 eligible employees
•COBRA enrollees are included in the medical underwriting of the group.
•Health information must be provided for COBRA enrollees along with the rest of the group.
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Deductible Credit
•Employees who are eligible and want to receive credit for deductible paid to prior carrier should
submit a copy of the Explanation of Benefits to Aetna (EOB) to us no later than 90 days after the
effective date. Note: this is for group-to-group takeover for individuals on the prior group plan.
•Employees may submit their EOBs with the initial submission of the New Business sold group, with
the first claim, or they can fax them to claims at 1-866-474-4040 no later than 90 days after the
effective date. If you choose to fax, please include “ECHS Category: SFRE” in the subject line with
the Group/Control Number in order to direct the information to the correct area for processing.
•Deductible carryover not allowed.
Deductible Funding
100% Plans Only
51 to 100 Eligible
Employees
•Plan sponsors must sign an attestation form certifying whether any underlying plan or third-party
arrangement is being used to subsidize the deductible.
•Groups cannot fund in excess of 50 percent of the deductible annually whether through an HRA,
HSA, CDHP or any other arrangement.
•Groups that do not meet the above guideline may have an additional factor applied.
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Dependent Eligibility
•Dependents must enroll in the same benefits as the employee (participation is not required).
•Employees may select coverage for eligible dependents under the dental plan even if they select
single coverage under the medical plan.
•Individuals cannot be covered as an employee and dependent under the same plan.
Eligible dependents include an employee’s:
•Spouse:
--If both husband and spouse/partner work for the same company they may enroll together
or separately.
•Domestic Partner:
--The employer must choose to cover domestic partners at initial underwriting of the group. If not
done at time of enrollment, approval of future request to add coverage for domestic partners
will be postponed until the group’s next anniversary date.
•Children:
--Medical and Dental:
--Children are eligible as defined in plan documents in accordance with state and federal law,
are eligible for medical and dental coverage up to age 26, regardless of financial dependency,
employment, eligibility of other coverage, student status, marital status, tax dependency or
residency. This requirement applies to natural and adopted children, stepchildren, and
children subject to legal guardianship.
--Children eligible for coverage through both parents cannot be covered by both parents under
the same plan.
--When the child works for the same company as the parent, the child may enroll separately as
an employee OR as a dependent under the parent’s plan.
--Grandchildren are eligible if court-ordered. A copy of the court order papers must
be submitted.
--Incapacitated child – attainment of limiting age will not terminate the coverage of the child
while the child is, and continues to be, both incapable of self-sustaining employment by
reason of mental retardation or physical handicap and chiefly dependent upon the employee
or member for support and maintenance. The employee or member must furnish proof of
incapacity and dependency within 31 days of the child’s attainment of the limiting age and
subsequently as we may require, but not more frequently than annually after the two-year
period following the child’s attainment of the limiting age.
--Dependent Life :
--2 to 50 eligible employees – children are eligible from 14 days of age up to their 19th birthday,
or up to their 23rd birthday, if in school on a regular basis and dependent solely on the
employee for support.
--51 to 100 eligible employees – contact your Aetna sales executive.
--AD&D or Disability:
--2 to 50 eligible employees – dependents are not eligible.
--51 to 100 eligible employees – contact your Aetna sales executive.
Effective Date
•The effective date must be the 1st or the 15th of the month.
•The effective date requested by the employer may be up to 60 days in advance.
Electronic Funds
Transfer (EFT/ACH)
•You can process the first month’s payment (for new business) through an electronic funds
transfer (EFT/ACH).
•Once the group is issued coverage, you can pay your monthly premiums online or by calling an
automated phone number, 1-866-350-7644, using your checking account and routing number.
There is no extra charge for this service.
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Employee Eligibility
2 to 50 Group Size
•Unless you specify otherwise, we will use this industry standard employee eligibility criteria
definition – an employee who works for a small employer on a full-time basis with a normal work
week of 25 hours or more.
•If your employee eligibility criteria differs from the above criteria (less than 25 hours), include your
actual definition on the employer application at the time of new business submission, subject to
underwriting approval.
•Eligible employees include union employees, even if currently covered under the union plan;
partners and proprietors.
•Eligible employees will NOT include part-time, temporary employees, seasonal employees,
substitute employees, independent contractors (1099), uncompensated employees, employees
making less than equivalent minimum wage, volunteers, retirees, inactive owners, officers who are
not active, managing members who are not active, investors or shareholders who are not otherwise
eligible and silent partners.
•Life and disability only – employees who are both disabled and away from work on the date their
insurance would otherwise become effective will become insured on the date they return to active
full-time work one full day.
Retirees
•2 to 50 eligible employees – not eligible.
--Medical – retirees are eligible. Groups with more than 10% Early/Non-medicare retirees will have
an additional factor applied.
--Dental – retirees cannot comprise more than 10% of the group.
--Life, disability or voluntary dental – retirees are not eligible.
--The retiree must be currently covered with present carrier (must be shown on the bill roster or
provide a copy of the ID card).
--If there were no retirees covered by the prior carrier the employee must be covered as an
employee on the bill roster.
--Provide the census for retirees, split by over and under age 65.
--Retirees are not to be included for purpose of counting employees to determine the size
of the group.
Employer
Contribution
Medical
•Single-choice – the employer must contribute at least 50% of the employee rate.
•Pick-A-Plan 4 – the employer must contribute 50% of the employee-only rate of whichever plan the
employee selects. The employer may choose to offer a defined contribution of at least $120 or the
actual cost of the plan chosen, whichever is less.
•2 to 50 eligible employees – groups that do not meet contribution are eligible to enroll during open
enrollment, November 15 through December 15, for a January 1 effective date.
Dental
•Employer must contribute at least 25% of the total cost or 50% of the cost of employee only
coverage for dental plans.
•If the employer contributes less than the above guideline, or if the coverage is 100% paid by the
employee coverage is deemed voluntary.
Life
•2 to 9 eligible employees – 100% of the total cost of the Basic Term Life plan.
•10 to 50 eligible employees – at least 50% of the total cost (excluding Optional Dependent Term Life).
•51 to 100 eligible employees – contact your Aetna sales executive.
•Coverage can be denied based on inadequate contributions.
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Employer Definition
2 to 50 Eligible
Employees
•“Small group employer” means an employer who employs at least 2 but no more than 50 eligible
employees on a typical business day during any one calendar year.
•Groups with 2 to 50 eligible employees that do not meet the above definition of a small employer
are not eligible for coverage.
Employer Eligibility
•All Aetna plans can be offered to sole proprietors, partnerships or corporations.
•Employers (companies/organizations) must not be formed solely for the purpose of obtaining
health coverage.
•Non-guaranteed associations, Taft-Hartley groups, professional employer organizations (PEOs)/
employee leasing firms, closed groups (groups that restrict eligibility through criteria other than
employment) and groups where no employee/employer relationship exists are not eligible for small
group coverage.
•Sole proprietor and partners are eligible even if there are no W-2 employees as long as there are
two eligible employees and participation is met.
•Dental and life products have ineligible industries, which are listed separately under Product
Specifications. The dental- and life-ineligible industry list does not apply when dental or life
is sold in combination with medical.
Newly formed businesses
Newly formed businesses must provide the following documents:
Sole proprietor
A copy of the Business License (not a professional license)
Partnership or limited
liability partnership
A copy of the Partnership Agreement
Limited liability company
A copy of the Articles of Organization and the Operating
Agreement to include the signature page(s) of all officers
Corporation
A copy of the Articles of Incorporation that includes the
signature page(s) of all officers (include a copy of the
Statement of Information within 30 days of filing with the state)
Each newly formed business must also provide:
•Proof of employer identification number/federal tax ID number (Social Security number if sole
proprietorship); and
•A copy of the UC018/UC020 (QWTS); if not available, must provide the most recent two
consecutive weeks of payroll records, which includes, for every eligible employee: first and last
name, hours worked, taxes withheld, SSN or last four digits, check number, wages earned including
those PT or in the WP; or
•A letter from a CPA with the following information if a QWTS or payroll records are not available:
1. A list of all employees, to include owners, partners, officers (full time and part time)
2. Number of hours worked by each employee
3. Weekly salary for each employee
4. Date of hire for each employee
5. Whether payroll records have been established
6. When will a QWTS UC018/UC020 be filed?
•51 to 100 eligible employees – the employer must complete a group medical questionnaire.
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Holding Companies
•Holding company – a holding company is a company that owns part, all or a majority of other
companies’ outstanding stock. It usually refers to a company that does not produce goods or services
itself; rather, its’ only purpose is owning shares of other companies. Holding companies allow the
reduction of risk for the owners and can allow the ownership and control of a number
of different companies.
•Parent company – a parent company is a holding company that owns enough voting stock in another
firm (subsidiary) to control management and operations by influencing or electing its board of
directors. A parent company could simply be a company that wholly owns another company.
Example
Bank A is the holding company (allows the smaller banks to raise more capital than a traditional bank).
Bank A (the holding company) has no ownership; it is simply an umbrella company for the three
Bank B locations.
Bank B has three locations and all under one TIN.
Bank A (the holding company) is under a separate TIN.
The holding company and banks have no ownership because the owners are all stockholders and
bank employees or bank executives.
There are no articles of incorporation, only stock certificates.
Bank B is the only group enrolling. Bank A is listed as an associated company with no employees and
the group is not to be enrolled.
Documentation needed: QWTS for Bank B, which should include all three locations.
Initial Premium
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•The first month’s premium may be submitted in the form of a check or electronic funds transfer.
•Either submit a “copy” of the initial premium check payable to Aetna or complete the EFT/ACH
form (Aetna Form) with the New Business group enrollment applications.
•If the EFT/ACH method is selected, we will withdraw the first initial premium from the checking
account when the group is approved. This is a one-time authorization for the first month premium
only. If a copy of the check is provided, once coverage is approved we will advise you where to mail
the initial premium check.
•The initial premium is not a binder check. We will determine final premium upon
underwriting review.
•If a customer withdraws a request for coverage, or if we deny the request due to business
ineligibility, we will not process the check and will return it to the employer.
•If the initial premium check is returned by the bank due to insufficient funds, we will follow the
standard termination process.
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Late Entrants
•An employee or dependent enrolling for coverage more than 31 days from the date first eligible
or 31 days of the qualifying event is considered a late enrollee.
•Applicants without a qualifying life event (for example, marriage, divorce, newborn child, adoption,
loss of spousal coverage, etc.) are subject to the late entrant guidelines as noted below.
•Voluntary cancellation of coverage is NOT a qualifying event. For example, if a spouse is covered
through his/her employer and voluntarily cancels the coverage, it is not a qualifying event to be
added to the other spouse’s plan. The spouse who cancelled the coverage must wait until the next
plan anniversary date to be eligible to be added.
Medical
•Late applicants without a qualifying event (for example, marriage, divorce, newborn child,
adoption, loss of spousal coverage, etc.) are not allowed and must wait for the group’s next renewal
date to enroll.
Dental
•An employee or dependent may enroll at any time, however, coverage is limited to preventive
and diagnostic services for the first 12 months.
•No coverage for most basic and major services for first 12 months (24 months for orthodontics).
•Late entrant provision does not apply to enrollees less than age five.
Life
•Late applicants will be deferred to the next plan anniversary date of the group and may reapply for
coverage 30 days before the anniversary date.
•The applicant must complete an individual health statement/questionnaire and provide evidence
of insurability (EOI).
•Life late enrollee example – group has $50,000 life with $20,000 guarantee issue limit. Late
enrollee enrolling for $50,000 would not automatically get the $20,000. Since the applicant is late
he or she must medically qualify for the entire $50,000.
Live/Work
Guidelines
•Employees enrolled in medical or dental who reside in a non-HMO/HNO and/or DMO network code
may enroll in an HMO/DMO product offered by their employer if they live within a 30-mile radius of
their work site that is within the HMO/DMO service area.
•Product availability for group benefit offerings is always determined by the ZIP Code of the employer.
•If the employee resides at a distance farther than the 30-mile radius, you can make exception
requests to the underwriting department for a feasibility determination.
•Employees who are enrolling using the Live/Work guidelines should include their home address and
ZIP Code as well as the work site address and ZIP Code. We will mail any correspondence to the
employee’s home address as listed on the application.
Medical
Underwriting
51 to 100 Eligible
Employees
•Groups applying for medical coverage are required to complete the Group Medical Questionnaire.
This will apply to medical coverage only. The group may be rated up.
•Waiver – eligible employees must complete the waiver section of the employee application, along
with their date of hire for either the employee and/or their dependents when declining coverage.
The medical questionnaire does not need to be completed for those individuals who are declining
medical or life at the guaranteed issue amount.
•Claims – medical claims may be reviewed for any individuals who had prior Aetna coverage and
used along with the health information included on the employee application(s) and/or Group
Medical Questionnaire, and included in the overall medical assessment of the group.
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Medicare Secondary
Payer (MSP) for CMS
Reporting
•Each year, all carriers must report to CMS (Centers for Medicare & Medicaid Services) the number of
Medicare Secondary Payer (MSP) groups and the number of employees, based on the number of
employees provided by the employer.
•MSP is the term used by Medicare when Medicare is not responsible for paying first. This is generally
when the Aetna plan would pay primary to Medicare for active employees and would pay first when
there are 20 or more total employees (full and part-time) for 20 or more weeks during this calendar
year or prior calendar year.
--Include: full-time, part-time, seasonal, temporary, union, owners, partners, officers
--Exclude: self-employed persons, independent contractors (1099), directors, leased employees
Option Sales
Alongside
Other Carriers
Medical
•Other insurance offered by the same employer is not a valid waiver.
•2 to 50 eligible employees – groups that do not meet participation are eligible to enroll during open
enrollment, November 15 through December 15, for a January 1 effective date.
•51 to 100 eligible employees – groups that do not meet participation may have an additional
factor applied.
Dental
•Options sales alongside another dental carrier are not allowed.
•All dental plans must be sold on a full-replacement basis.
Term life, disability or packaged life & disability
•Options sales alongside another life or packaged life & disability carrier are not allowed.
•All life, disability or packaged life & disability plans must be sold on a full-replacement basis only.
Out of Area
Employees
Within Arizona
Medical
•Employees residing outside of an Arizona Aetna network service area must enroll in either the
Arizona PPO or the Aetna indemnity plan.
•The Aetna indemnity plan is only available if the employee resides outside of both the Arizona
Aetna PPO network service area and the Arizona Aetna HMO network service area.
Dental
•Employees who reside within Arizona but outside of a DMO service area may be offered an in-state
PPO plan.
Term life, disability or packaged life & disability
•2 to 50 eligible employees – employees are eligible for the same life plan selected by the employer.
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Out-of-State
Employees
Medical
•Out-of-state employees who reside in an out-of-state PPO network will receive the Arizona standard
PPO product (inclusive of any required extraterritorial benefits).
•Out-of-state employees who do not reside in an out-of-state PPO network area will receive the
Arizona standard indemnity products (inclusive of any required extraterritorial benefits).
•HMO, HNO, Savings Plus and Aetna Whole Health network plans are not allowed outside of Arizona.
Network availability for out-of-state employees
•Health coverage is not available in HI or VT.
•PPO is not available in ND.
•Louisiana residents – out-of-state employees residing in LA are required to have a separate plan
quoted and sold based on LA rates and benefits. These employees are still underwritten as part of the
group; however, the plans and rates for the LA members will not be based on where the employer is
located. This will require Louisiana employer and employee applications to be completed.
Dental
•Members who reside out-of-state will receive the same plan as in-state members (based on state
rules and network availability). This applies to DMO, PPO and FOC Dental Plans.
•If an out-of-state member resides in a state that does not allow the in-state plan, those members
will be placed into an available PPO or indemnity plan.
Life
•2 to 50 eligible employees – out-of-state employees are eligible for the option selected by
the employer.
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Participation
Medical
Noncontributory plans
•100% participation is required. All employees, excluding those with coverage through another
employer’s plan, must enroll.
Contributory plans
•2 to 3 eligible employees – 100% of eligible employees, excluding valid waivers.
•4 to 50 eligible employees – 75% of eligible employees excluding valid waivers, rounding down.
•51 to 100 eligible employees – 75% of eligible employees excluding valid waivers, rounding down
and a minimum of 50% of total eligible employees must enroll.
•Pick-A-Plan 4 – 75% participation, with a minimum of five enrolled.
•Groups that do not meet participation are eligible to enroll during open enrollment, November 15
through December 15, for a January 1 effective date.
•Groups that do not meet participation may have an additional factor applied.
•All employees waiving coverage must complete the waiver section.
•Dependent participation is not required.
Waivers
•Valid waivers include:
-- Spousal/parental group coverage
--Medicare/Medicaid
--Champus/ChampVA
--Military coverage
--Retiree coverage
--Association coverage (for doctors/lawyers covered under an association who want to
cover their employees).
•Invalid waivers include:
-- Individual coverage (on and off exchange)
-- Student health
-- Another employer sponsored health plan
•Waivers – all employees waiving coverage must complete the waiver section of the
employee application.
•Proof of coverage may be requested at the underwriter’s discretion.
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Participation
Dental
Noncontributory plans
•100% excluding valid waivers.
Contributory plans with medical or standalone (round to the nearest)
•Standard plans:
--2 to 3 eligible employees – 100% excluding valid waivers with a minimum of 2 enrolled.
--4 to 50 eligible employees – 75% excluding valid waivers. A minimum of two and 50% of total
eligible employees must enroll in the dental plan.
--51 to 100 eligible employees – 30% excluding valid waivers.
•Voluntary plans:
--3 to 100 eligible employees – 30% excluding valid waivers.
--Minimum of three must enroll.
--If a group does not qualify for a standard plan and has 30% or more participation then group
qualifies for voluntary.
Valid waivers include:
•Spousal group coverage
•Parental group coverage
•Champus/ChampVA
•Military coverage
•Retiree coverage
•Association coverage (for doctors/lawyers covered under an association who want to cover
their employees)
Standard and voluntary plans
•Employees may select coverage for eligible dependents under the dental plan even if they elected
single coverage on the medical plan, or vice versa.
•Coverage can be denied based on inadequate participation.
Participation Life
•100% participation.
•Noncontributory – 100% participation.
•Contributory – 75% participation.
•Contact your Aetna sales executive.
Standalone life
•75% participation.
All plans
•COBRA enrollees are not eligible for life insurance.
•Retirees are not eligible.
•Employees may elect life insurance even if they do not elect medical coverage and the group must
meet the required participation percentage. If not, then life will be declined for the group.
Example
Nine employees
Three waiving medical
Nine must enroll for life
•Coverage can be denied based on inadequate participation.
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Professional
Employer
Organization (PEO)
Groups Covered
Under a PEO
•As long as the PEO provides payroll specific for the enrolling group and we can determine the size
and eligibility of the group, even though the group may be reported under the PEO tax ID, the group
may be considered subject to underwriting approval.
•A letter of intent is not needed.
Pick-A-Plan
Medical Only
•Groups of two to four enrolled employees may offer any combination of two plans.
•Groups of five or more enrolled employees may offer any combination of four plans.
•Employer must contribute 50% of the employee-only rate of whichever plan the employee selects.
•The plans are based on the full census of the group so actual enrollment in each plan will not cause
the rates to change, however if the sold case has a different overall census than the quote,
it will need to be re-rated.
Product Availability
Medical
•Groups of 100 or fewer eligible employees.
•May be written standalone or with ancillary coverage as noted in the following columns
•Only non-occupational injuries and disease will be covered.
Dental
•1 life:
--Not available.
•2 eligible employees:
--Standard dental available with medical.
--Voluntary dental not available.
--Orthodontic coverage not available.
--Standard and voluntary plans available with or without medical.
--Standalone available.
--Standalone dental has ineligible industries, which are listed separately under the SIC code section
of the guidelines.
•Orthodontic coverage – available to dependent children only for groups of 10 or more eligible
employees with a minimum of five enrolled employees for both standard and voluntary plans.
Life
•1 life – not available.
•2 to 9 eligible employees – if sold with medical.
•10 to 50 eligible employees – if sold with medical or dental.
•26 to 50 eligible employees – on a standalone basis.
•51 to 100 – contact your Aetna sales executive.
Packaged life and disability
•2 to 50 eligible employees – if sold with medical.
•10 to 50 eligible employees – on a standalone basis.
•51 to 100 eligible employees – not available.
•A plan sponsor cannot purchase both life and packaged life and disability plans.
•Product packaging rule is a group level requirement. Employees will be able to individually elect life,
disability or packaged life & disability insurance even if they do not elect medical coverage.
Rate Structure
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•2 to 9 enrolled employees – tabular rates based on each member’s age.
•10 to 100 enrolled employees – composite rates.
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Replacing Other
Group Coverage
•Do not cancel any existing medical coverage until you have been notified of approval from the
Aetna Underwriting unit.
•Dental – provide a copy of the benefit summary to verify:
--Major and orthodontic coverage for Standard 2 to 9 eligible employees and Voluntary
3 to 100 eligible employees; and
--Preventive and basic coverage for Voluntary plans.
Signature Dates
•The Aetna Employer Application and all employee applications must be signed and dated before
and within ninety (90) days of the requested effective date.
•All employee applications must be completed by the employee himself/herself.
Spinoff Groups
(current Aetna
customers leaving
an Aetna group only)
We will consider the group with the following, subject to underwriting approval:
Tax Documents
for Groups with
2 to 9 ENROLLED
Employees AND
10 to 50 ENROLLED
Employees with
NO Prior Coverage
A Quarterly Wage and Tax Statement (QWTS) is needed containing the names, salaries, etc., of all
employees of the employer group
•A letter from the group or broker indicating the group is enrolling as a spinoff. The letter needs
to include the name of the group they are spinning off from.
•Ownership documents showing that the spinoff company is a newly formed separate entity.
•A minimum of two weeks payroll. If the group that is spinning off has been in business longer than
two weeks, payroll will be required for the amount of time in business up to a maximum of
six consecutive weeks.
•51 to 100 eligible employees – medical claims may be reviewed along with the health information
included on the employee application and included in the overall medical assessment of the group.
•Newly hired employees, terminated or part-time employees should be noted on the QWTS
•Reconciled QWTS should be signed and dated by the employer
•If a QWTS is not available, explain why and provide a copy of payroll records
•Seasonal industries, such as lawn and garden services, construction, concrete and paving, golf
courses, farm laborers, etc., must provide four consecutive quarters of wage and tax reports to
verify consistent, continuous employment of eligible employees.
•Churches must provide Form 941, including a copy of the payroll records with employee names,
wages and hours, which must match the totals on Form 941
•Sole proprietors, partners or officers of the business who do not appear on the QWTS should
submit one of the following identified documents. This list is not all-inclusive. The employer may
provide any other documentation to establish eligibility.
Sole proprietor
•Franchise
•Limited liability company
(operating as a sole
proprietor)
Partner
•Partnership
•Limited liability partnership
•IRS Form 1040 along with Schedule C (Form 1040)
•IRS Form 1040 along with Schedule SE (Form 1040)
•IRS Form 1040 along with Schedule F (Form 1040)
•IRS Form 1040 along with Schedule K-1 (Form 1065)
•Any other documentation the owner would like to provide
to help determine eligibility
•IRS Form 1065 Schedule K-1
•IRS Form 1120 S (Schedule K-1) along with Schedule E (Form 1040)
•Partnership agreement if established within two years
listing partners
73
U
Tax Documents
for Groups with
2 to 9 ENROLLED
Employees AND
10 to 50 ENROLLED
Employees with
NO Prior Coverage
Corporate officer
•S-corporation
•Personal service
corporation
Corporate officer
•C-corporation
•Limited liability company
(LLC) operating as C-corp
•IRS Form 1120 S (Schedule K-1) along with Schedule E (Form 1040)
•IRS Form 1120 W (Personal Service Corp)
•IRS Form 1040 ES (Estimated Tax) (S-Corp)
•IRS Form 8832 (Entity classification as a corporation)
•W-2
•Articles of Incorporation if established within two years
listing corporate officers
• If the officers/owners are on the quarterly wage and tax
statement, no additional documents are needed.
•1120 (Corporation Income Tax Return)
•1120A (Corporation Short-Form Income Tax Return)
•Articles of Incorporation if established within two years –
corporate officers must be listed
•Any other documentation the owners would like to provide
Tax Documents
for Groups with
10 to 50 ENROLLED
Employees with
Prior Coverage
•No documentation is required – a QWTS or prior carrier bill not needed.
•Upon request, the underwriter will contact the broker if a QWTS is necessary.
Townships and
Municipalities
•A township is generally a small unit that has the status and powers of local government.
•A municipality is an administrative entity composed of a clearly defined territory and its population,
and commonly denotes a city, town or village. A municipality is typically governed by
a mayor and city council, or municipal council. In most counties, a municipality is the smallest
administrative subdivision to have its own democratically elected officials.
Underwriting requirements
•Quarterly Wage and Tax Statement (QWTS).
•W-2: Elected or Appointed officials and Trustees “may” be eligible for group coverage based on the
charter or legislation. If so, they may not be on the QWTS; rather, they may be paid via W-2.
In that case, obtain a copy of their prior year W-2.
•If elected officials are to be covered, provide a copy of the charter or contract indicating which
classes or employees are to be covered, the minimum hours required to work per week to be eligible
for coverage, and confirmation that coverage will be offered to all employees meeting
the minimum number and participation will be maintained.
Vision
74
•Available to groups of two or more with no minimum participation or contribution.
•The employer may only offer one vision plan to all employees.
•To enroll, submit a list of employees and dependents with vision plan indicated. You can send the
list by e-mail, Word doc, Excel, or eList. Or, you can mark vision on the employee application.
•You may include the initial premium with payment for medical, dental or life, or you may include a
separate payment.
•Waivers are not needed as participation is not required.
U
Dental only
Coverage Waiting
Period
Standard 2 to 9 eligible employees and voluntary 3 to 100 eligible employees
•PPO and indemnity plans – for major and orthodontic services employees must be an enrolled
member of the employer’s plan for one year before becoming eligible.
•DMO – there is no waiting period.
•Discount plans do not qualify as previous coverage.
•Future hires – waiting period applies regardless if takeover for voluntary.
•Virgin group (no prior coverage) – the waiting periods apply to employees at case inception as well
as any future hires.
•Takeover/Replacement cases (prior coverage) – you must provide a copy of the last billing
statement and schedule of benefits in order to provide credit. If a group’s prior coverage did not
lapse more than 90 days prior, the waiting periods are waived. In order for the waiting period to be
waived, the group must have had a dental plan in place that covered major (and orthodontic, if
applicable) immediately preceding our takeover of the business.
Example
Prior major coverage but no orthodontic coverage.
Aetna plan has coverage for both major and orthodontic.
The waiting period is waived for major services but not for orthodontic services.
Standard 10 to 100 eligible employees
•No waiting period.
Creditable Prior
Coverage
•Plans that cover preventive and basic services will satisfy our requirements for having prior
creditable coverage as long as the member was covered for 12 months under a dental plan within
the last 90 days that included both preventive and basic coverage. You must provide a copy of the
schedule of benefits to receive credit.
•Preventive only or discount plans do not meet the requirements for having prior creditable
coverage. These groups will continue to be written has having no prior coverage.
Open Enrollment
An “open” enrollment is a period when any employee can elect to join the dental plan without
penalty, regardless if they previously declined coverage during the first 31 days of initial eligibility.
Standard plans with medical or standalone
•2 to 9 eligible employees – no open enrollment.
•10 to 100 eligible employees – employees/dependents who do not enroll when initially eligible are
now eligible to enroll during a subsequent open enrollment period without being subject to the late
entrant provision. Voluntary plans with medical or standalone
•2 to 100 eligible employees – no open enrollment.
Option Sales
•Option sales alongside another dental carrier are not allowed.
Reinstatement
•All dental plans must be sold on a full replacement basis.
•Voluntary plans only – members once enrolled who have previously terminated their coverage by
discontinuing their contributions may not re-enroll for a period of 24 months. All coverage rules will
apply from the new effective date including, but not limited to, the coverage waiting period.
75
Dental only
Ineligible Industries
76
•All industries are eligible if sold with medical.
•The following industries are not eligible when dental is sold standalone or packaged only with life.
7933 – 7933
Bowling Centers
7991 – 7991
Physical Fitness Facilities
8611 – 8611
Business Associations
8811 – 8811
Private Households
7911 – 7911
Dance Studios, Schools
8621 – 8651
Professional Membership
Organizations, Labor Unions,
Civic Social and Fraternal
Orgs, Political Orgs
7361 – 7363
Employment Agencies
7941 – 7948
Professional Sports Clubs
& Producers, Race Tracks
7999 – 7999
Miscellaneous Amusement/
Recreation
7992 – 7997
Public Golf Courses,
Amusements, Membership
Sports & Recreation Clubs
8699 – 8699
Miscellaneous
Membership Org
8661 – 8661
Religious Organizations
8999 – 8999
Miscellaneous Services
7922 – 7929
Theatrical Producers, Bands,
Orchestras, Actors
76
U
Life only – 2 to 50 eligible employees
Job Classification
(Position) Schedules
Guaranteed Issue
Coverage
•Varying levels of coverage based on job classifications are available for groups with 10 or more lives.
•Up to three separate classes are allowed (with a minimum requirement of three employees
in each class).
•Items such as probationary periods must be applied consistently within a class of employee.
•The benefit for the class with the richest benefit must not be greater than five times the benefit of
the class with the lowest benefit. For example, a schedule may be structured as follows:
Position/Job Class
Basic Term Life Amount
Packaged Life & Disability
Executives
$50,000
High Option
Managers, Supervisors
$20,000
Medium Option
All Other Employees
$10,000
Low Option
•Aetna provides certain amounts of life insurance to all timely entrants without requiring an employee
to answer any medical questions. These insurance amounts are called “guaranteed issue.”
•Employees wishing to obtain increased insurance amounts will be required to submit evidence of
insurability, which means they must complete a medical questionnaire and may be required to
provide medical records.
•On-time enrollees who do not meet the requirements for evidence of insurability will receive the
guaranteed issue life insurance amount.
Case Size
Basic Term Life Amount
$50,000
$75,000
$100,000
•Late enrollees must qualify for the entire amount and are not guaranteed any coverage.
Actively at work
•Employees who are both disabled and away from work on the date their insurance would otherwise
become effective will become insured on the date they return to active full-time work one full day.
Continuity
of Coverage
(no loss/no gain)
•The employee will not lose coverage due to a change in carriers. This protects employees who are
not actively at work during a change in insurance carriers.
•If an employee is not actively at work, we will waive the actively-at-work requirement and provide
coverage for a maximum of 12 months from the policy effective date, except no benefits are
payable if the prior plan is liable. If the employee has not returned to active work before the end of
the 12-month period, conversion must be offered.
77
U
Evidence of
Insurability (EOI)
Evidence of insurability means the person must complete an individual health statement and may
have to submit to medical evidence via medical records at their expense. EOI is required when one or
more of the following conditions exist:
1. Life insurance coverage amounts requested are above the guaranteed standard issue limit.
2. Late entrant – coverage is not requested within 31 days of eligibility for contributory coverage.
3. New coverage is requested during the anniversary period.
4. Coverage is requested outside of the employer’s anniversary period due to qualifying life event
(for example, marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.)
5. Reinstatement or restoration of coverage is requested.
6. Dependent coverage option was initially refused by employee but requested later. The dependent
would be considered a late entrant and subject to EOI, and may be declined for medical reasons.
7. Requesting life or disability at the individual level and they are a late enrollee even if enrolling on
the case anniversary date. Late enrollees are not eligible for the guarantee issue limit.
Example
Group has $75,000 life with $50,000 guarantee issue limit.
Late enrollee enrolling for $75,000 would not automatically get the $50,000.
Since the applicant is late, they must medically qualify for the entire $75,000.
Open Enrollment
•Prohibited
Packaged life/disability only and disability only ineligible industries
2 – 50 eligible employees
Description
78
SIC code(s)
Description
SIC code(s)
Asbestos Products
3291 – 3292
Motion Picture/Amusement &
Recreation
7800 – 7999
Automotive Repairs/Services
7500 – 7599
Non-classified Establishments
9999
Doctor’s Offices Clinics
8010 – 8043
Primary Metal Industries
3310-3329
Explosives, Bombs &
Pyrotechnics
2892 – 2899
Real Estate – Agents
6531
Fire Arms & Ammunition
3480 – 3489
Security Brokers
6211
Liquor Stores
5921
Service - Detective Services
7381
Membership Associations
8600 – 8699
Service - Private Household
8800 – 8899
Mining
1000 – 1499
U
(continued)
Life ineligible industries 10-100 eligible employees
Description
SIC code(s)
Description
SIC code(s)
Hunting, Trapping & Game
Propagation
971
348X
Mining - Metal
10XX
Trucking & Courier Services,
except Air
421X
Mining - Coal
12XX
Transportation – Water/Air
44XX – 45XX
Mining - Oil and Gas
13XX
Detective, Guard & Armored Car
Service
7381
Mining - Nonmetallic Minerals,
Except Fuels
14XX
Amusement Parks
7996
Manufacturing – Logging &
Sawmills
241X – 242X
Memberships Sports and
Recreation Clubs
7997
Manufacturing – Industrial
Inorganic Chemicals
281X
County/Cities/Municipalities
91XX*
Manufacturing – Fertilizers/
Pesticides/Explosives
2865 – 2892
Public Order and Safety
922X
Manufacturing – Lime/Gypsum/ 3274 – 3281
Stone Products
National Security
9711
Asbestos Products
Nonclassified Establishments
9999
329X
Short term and long term disability ineligible industries
10-100 eligible employees
Description
SIC code(s)
Description
SIC code(s)
Agriculture, Forestry, Fishing
01XX – 09XX
Transportation – Water/Air
44XX – 45XX
Mining
10XX – 14XX
Transportation Services
478X
General Building Contractors
- Residential
152X – 154X
Sanitary Services
495X
Highway & Street Construction
161X
Automotive Dealers & Gasoline
Stations
55XX
Bridge Tunnel & Elevated
Highway
162X
Liquor Stores
5921
Roofing, Siding, Sheet Metal
1761
Fuel Dealers
598X
*51 – 100: If Police and Fire Staff are 20% or less of the group, quote will be completed.
79
U
(continued)
80
Concrete Work
1771
Security/Commodity Brokers &
Dealers
Construction Special Trade
Contractors
1791
Real Estate Agents and Managers 6531
Excavation Work
1794
Hotels, Rooming Houses, Camps
70XX
Wrecking and Demolition Work
1795
Laundry, Cleaning & Garment
Services
721X
Meat Processing
201X
Beauty Shops
723X
Manufacturing – Tobacco
Products
21XX
Barber Shops
724X
Manufacturing – Logging &
Sawmills
241X – 242X
Shoe Repair Shops
725X
Pulp Mills
2611
Misc Personal Services
7299
Paper Mills
2621
Services to Dwellings and Other
Buildings
734X
Paperboard Mills
2631
Detective, Guard & Armored Car
Services
7381
Alkalies & Chlorine
2812
Automotive Repair & Services
75XX
Industrial Gases
2813
Motion Pictures
78XX
Manufacturing – Fertilizers/
Pesticides/Explosives
2865 – 2892
Amusement & Recreation
Services
79XX
Petroleum Refining
29XX
Offices & Clinics of Medical
Doctors
801X – 8049
Manufacturing – Asbestos
Products
3274 – 3281
Skilled Nursing Facilities
8051
Asbestos Products
3291 – 3299
Child Day Care Services
8351
Primary Metal Industries
3310 – 3325
Membership Organizations
86XX
Nonferrous Foundries
336X
Service - Private Households
88XX
348X
Services NEC
8999
Transportation – Railroad
40XX
County/Cities/Municipalities
91XX – 92XX*
Transportation – Taxicabs/
Buses/Trucking
41XX – 42XX
National Security
9711
US Postal Service
4311
Nonclassified Establishments
9999
*51 – 100: If Police and Fire Staff are 20% or less of the group, quote will be completed.
62XX
Limitations and exclusions
Medical
These plans do not cover all health care expenses and include
exclusions and limitations. Members should refer to their plan
documents to determine which health care services are
covered and to what extent. The following is a partial list of
services and supplies that are generally not covered. However,
the plan documents may contain exceptions to this list based
on state mandates or the plan design purchased.
Aetna HMO and HNOption
•All medical and hospital services not specifically covered
or that are limited or excluded by the plan documents,
including costs of services before coverage begins and
after coverage terminates
•Blood and blood by-products, except as administered on an
inpatient or emergency care basis
•Cosmetic surgery
•Custodial care
•Dental care and dental X-rays
•Donor egg retrieval
•Experimental and investigational procedures (except for
coverage for medically necessary routine patient care costs
for members participating in a cancer clinical trial)
•Hearing aids, unless specifically listed as covered in the plan
documents
•Home births
•Implantable drugs and certain injectable drugs, including
injectable infertility drugs
•Infertility services, including artificial insemination and
advanced reproductive technologies, such as IVF, ZIFT, GIFT,
ICSI and other related services, unless specifically listed as
covered in the plan documents
•Long-term rehabilitation
•Nonmedically necessary services or supplies
•Orthotics, except diabetic orthotics
•Outpatient prescription drugs (except for treatment of
diabetes), unless covered by a prescription plan rider, and
over-the-counter medications (except as provided in a
hospital) and supplies
•Radial keratotomy or related procedures
•Reversal of sterilization
•Services for the treatment of sexual dysfunction or
inadequacies, including therapy, supplies or counseling
or prescription drugs
•Special duty nursing
•Therapy or rehabilitation, other than those listed as covered
•Treatment of behavioral disorders
•Weight-control services, including surgical procedures,
medical treatments, weight control/loss programs, dietary
regimens and supplements, appetite suppressants and other
medications; food or food supplements, exercise programs,
exercise or other equipment; and other services and supplies
that are primarily intended to control weight or treat obesity,
including morbid obesity, or for the purpose of weight
reduction, regardless of the existence of comorbid conditions,
unless specifically listed as covered in the plan documents
Aetna PPO and Indemnity
•All medical or hospital services that are not specifically
covered or that are limited or excluded in the plan
documents
•Charges related to any eye surgery, mainly to correct
refractive errors
•Cosmetic surgery, including breast reduction
•Custodial care
•Dental care and X-rays
•Donor egg retrieval
•Experimental and investigational procedures
•Hearing aids, unless specifically listed as covered in the plan
documents
•Infertility services, including, but not limited to, artificial
insemination and advanced reproductive technologies, such
as IVF, ZIFT, GIFT, ICSI and other related services, unless
specifically listed as covered in the plan documents
•Nonmedically necessary services or supplies
•Orthotics, as specified in the plan
•Over-the-counter medications and supplies
•Reversal of sterilization
•Services for the treatment of sexual dysfunction or
inadequacies, including therapy, supplies and counseling
•Special-duty nursing
•Weight-control services, including surgical procedures,
medical treatments, weight control/loss programs, dietary
regimens and supplements, appetite suppressants and
other medications; food or food supplements, exercise
programs, exercise or other equipment; and other services
and supplies that are primarily intended to control weight
or treat obesity, including morbid obesity, or for the purpose
of weight reduction, regardless of the existence of comorbid
conditions, unless specifically listed as covered in the
plan documents
81
Dental, AD&D Ultra and disability
AD&D Ultra
Dental, AD&D Ultra and disability plans include limitations,
exclusions and charges or services that these plans do not
cover. For a complete listing of all limitations and exclusions
or charges and services that are not covered, please refer to
your Aetna group plan documents. Limitations, exclusions
and charges or services may vary by state or group size.
Not all events that may be ruled accidental are covered
by this plan. No benefits are payable for a loss caused or
contributed to by:
Dental
Listed below are some of the charges and services for which
these dental plans do not provide coverage. For a complete
list of exclusions and limitations, refer to the plan documents.
•Dental services or supplies that are primarily used to alter,
improve or enhance appearance
•Experimental services, supplies or procedures
•Treatment of any jaw joint disorder, such as
temporomandibular joint disorder
•Replacement of lost, missing or stolen appliances and
certain damaged appliances
•Those services that Aetna defines as not necessary for the
diagnosis, care or treatment of a condition involved
•Specific service limitations:
--DMO plans: Oral exams (4 per year)*
--PPO plans: Oral exams (2 routine and 2 problem-focused
per year)
--All plans:
--Bitewing X-rays (1 set per year)*
--Complete series X-rays (1 set every 3 years)*
--Cleanings (2 per year)*
--Fluoride treatments (1 per year; children under 16)
--Sealants (1 treatment per tooth, every 3 years on
permanent molars; children under 16)*
--Scaling and root planing (4 quadrants every 2 years)
--Osseous surgery (1 per quadrant every 3 years)
•All other limitations and exclusions in the plan documents
Employee and dependent life insurance
The plan may not pay a benefit for deaths caused by suicide,
while sane or insane, or from an intentionally self-inflicted
injury, within two years from the effective date of the
person’s coverage. If death occurs after two years of the
effective date but within two years of the date that any
increase in coverage becomes effective, no death benefit
will be payable for any such increased amount.
82
•Air or space travel, unless a person is a passenger, with
no duties at all, on an aircraft being used only to carry
passengers (with or without cargo)
•Bodily or mental infirmity
•Commission of or attempting to commit a criminal act
•Illness, ptomaine or bacterial infection**
•Inhalation of poisonous gases
•Intended or accidental contact with nuclear or atomic
energy by explosion and/or release
•Ligature strangulation resulting from autoerotic
asphyxiation
•Intentionally self-inflicted injury
•Medical or surgical treatment**
•Third-degree burns resulting from sunburn
•Use of alcohol
•Use of drugs, except as prescribed by a physician
•Use of intoxicants
•Use of alcohol or intoxicants or drugs while operating any
form of a motor vehicle whether or not registered for land,
air or water use. A motor vehicle accident will be deemed
to be caused by the use of alcohol, intoxicants or drugs
if it is determined that at the time of the accident the
member was:
--Operating the motor vehicle while under the influence of
alcohol at a level that meets or exceeds the level at which
intoxication would be presumed under the laws of the
state where the accident occurred. If the accident occurs
outside of the United States, intoxication will be presumed
if the person’s blood alcohol level meets or exceeds .08
grams per deciliter; or
--Operating the motor vehicle while under the influence
of an intoxicant or illegal drug; or
of a prescription drug in excess of the amount prescribed
by the physician; or
of an over-the-counter medication taken in an amount
above the dosage instructions.
•Suicide or attempted suicide (while sane or insane)
•War or any act of war (declared or not declared)
*The frequent calendar-year limits for these services will not apply to the DMO plans if they are needed more frequently due to
medical necessity.
**These do not apply if the loss is caused by:
- An infection that results directly from the injury
- Surgery needed because of the injury
The injury must not be one that is excluded by the terms of this section.
Disability
Vision
Disability coverage also does not cover any disability that:
Go practically anywhere for your eye care. With Aetna Vision
Preferred, you can see any provider you want, in the network
or out. The Aetna Vision Preferred network is extensive, with
over 60,000 providers to choose from. We have a balanced
network of independent eye doctors and top retail providers
including LensCrafters, Pearle Vision, Sears Optical, Target
Optical and JC Penney Optical. Members can get an eye
exam at one provider and eyewear at another, if they choose.
Many of our providers offer the option to schedule an
eye exam online and have glasses ready within an hour.
Visit www.aetnavision.com to find a network vision care
provider in our plan.
•Is due to an occupational illness or occupational injury
except in the case of sole proprietors or partners who
cannot be covered by workers’ compensation
•Is due to insurrection, rebellion, or taking part in a riot
or civil commotion
•Is due to intentionally self-inflicted injury (while sane
or insane)
•Is due to war or any act of war (declared or not declared)
•Results from the commission of, or attempting to commit
a criminal act
•Results from a motor vehicle accident caused by operating
the vehicle while the member is under the influence of
alcohol. A motor vehicle accident will be deemed to be
caused by the use of alcohol if it is determined that at the
time of the accident the member was operating the motor
vehicle while under the influence of alcohol at a level that
meets or exceeds the level at which intoxication would be
presumed under the laws of the state where the accident
occurred. If the accident occurs outside of the United
States, intoxication will be presumed if the person’s blood
alcohol level meets or exceeds .08 grams per deciliter
Disability coverage does not cover any disability on any
day that the member is confined in a penal or correctional
institution for conviction of a criminal act or other public
offense. The member will not be considered to be disabled,
and no benefits will be payable.
No benefit is payable for any disability that occurs during the
first 12 months of coverage and is due to a pre-existing
condition for which the member was diagnosed, treated or
received services, treatment, drugs or medicines three
months prior to the coverage effective date.
Vision insurance plans are underwritten by Aetna Life
Insurance Company (Aetna). Certain claims administration
services are provided by First American Administrators, Inc.
and certain network administration services are provided
through EyeMed Vision Care (“EyeMed”), LLC.
Providers participating in the Aetna Vision network are
contracted through EyeMed Vision Care, LLC. EyeMed and
Aetna are independent contractors and not employees or
agents of each other. Participating vision providers are
credentialed by and subject to the credentialing requirements
of EyeMed. Aetna does not provide medical/vision care or
treatment and is not responsible for outcomes. Aetna does
not guarantee access to vision care services or access to
specific vision care providers and provider network
composition is subject to change without notice.
Benefits are not provided for services or materials arising
from: Orthoptic or vision training, subnormal vision aids
and any associated supplemental testing; Aniseikonic lenses;
Medical and/or surgical treatment of the eye, eyes or
supporting structures; Any eye or vision examination, or
any corrective eyewear required by a policyholder as a
condition of employment; safety eyewear; Services provided
as a result of any Workers’ Compensation law, or similar
legislation, or required by any governmental agency or
program whether federal, state or subdivisions thereof;
Plano (nonprescription) lenses and/or contact lenses;
Nonprescription sunglasses; Two pair of glasses in lieu
of bifocals; Services or materials provided by any other group
benefit plan providing vision care; Certain brand-name
vision materials in which the manufacturer imposes a
no-discount policy; or services rendered after the date an
insured person ceases to be covered under the policy, except
when vision materials ordered before coverage ended are
delivered, and the services rendered to the insured person
are within 31 days from the date of such order. Lost or broken
lenses, frames, glasses, or contact lenses will not be replaced
except in the next benefit frequency when vision materials
would next become available. Benefits may not be combined
with any discount, promotional offering, or other group
benefit plans.
83
New business checklist
It’s so easy
To help ensure the underwriting of your case is quick and easy, we are providing this simple checklist.
¨¨ 1. Employer application
¨¨ 2. Employee enrollment and waiver applications
-- For all eligible employees enrolling or waiving
health coverage
-- Waivers may be submitted in a separate Excel
spreadsheet with the reason for waiving included
Or e-listing
-- Enrollment census must include plan selection
-- Be sure and include a separate listing for waivers
with the reason for waiving included
¨¨ 3. C
opy of initial premium check payable to
Aetna or ACH form
¨¨ 4. Wage and tax statement
-- 2 to 9 enrolled employees – Quarterly Wage and
Tax Statement(QWTS)
-- 10 to 50 enrolled with no prior coverage – QWTS
-- 10 to 50 enrolled with prior coverage – upon request,
the underwriter will contact you if a QWTS is necessary
¨¨ 5. D
ental benefit summary
-- For major and ortho credit for Standard 2 to 9 and
Voluntary 3 to 100; and preventive and basic credit
for Voluntary plans
¨¨ 6. Illustrative quote with sold plan marked
-- Signed and dated by the plan sponsor
¨¨ 1. Employer application
¨¨ 2. Employee enrollment and waiver applications
-- For all eligible employees enrolling or waiving
health coverage
-- Waivers may be submitted in a separate Excel
spreadsheet with the reason for waiving included
Or e-listing
-- Enrollment census must include plan selection
-- Be sure and include a separate listing for waivers
with the reason for waiving included
¨¨ 3. Group medical questionnaire
¨¨ 4. Copy of most current medical prescreen evaluation
(if applicable)
¨¨ 5 C
opy of initial premium check payable to
Aetna or ACH form
¨¨ 6. C
urrent renewal rate and plan design
-- For Voluntary Dental also include benefit summary for
major and ortho credit, and preventive and basic credit
¨¨ 7. Signed quote with sold plan marked and census
[email protected]
Any missing information may result in the effective date
being moved forward to the next available date.
Send all enrollment materials to:
[email protected]
Secure File Transport (FTP): https://st3.aetna.com
If you do not have access to the FTP server, please
contact your Aetna Sales Executive for access or visit
us at Producer World.
Effective dates may be the 1st or 15th of the month.
Effective date
Submission deadline
1st and 15th
of month
End of the business day after
the effective date
For assistance with your new
case submissions contact your
Aetna sales manager or call us
at 1-877-249-2472.
84
This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain
coverage. Rates and benefits may vary by location. Health/Dental benefits, health/dental insurance and life and disability insurance
plans/policies contain exclusions and limitations. Health information programs provide general health information and are not a
substitute for diagnosis or treatment by a physician or other health care professional. Plan features and availability may vary by
location and group size. Aetna HealthFund HRAs are subject to employer-defined use and forfeiture rules and are unfunded
liabilities of your employer. Fund balances are not vested benefits. Investment services are independently offered through
HealthEquity, Inc. Discount programs provide access to discounted prices and are NOT insured benefits. The member is responsible
for the full cost of the discounted services. Plan for Your Health is a public education program from Aetna and The Financial Planning
Association. If you are in a plan that requires the selection of a primary care physician and your primary care physician belongs to an
integrated delivery system or physician group, your primary care physician will generally refer you to specialists and hospitals that
are affiliated with the delivery system or physician group. Providers are independent contractors and not agents of Aetna. Provider
participation may change without notice. Aetna does not provide care or guarantee access to health services. Not all health, dental
and disability services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions
of coverage. Plan features may vary, may be unavailable in some states, and are subject to change. Aetna receives rebates from drug
manufacturers that may be taken into account in determining Aetna’s Preferred Drug List. Rebates do not reduce the amount a
member pays the pharmacy for covered prescriptions. The Aetna Personal Health Record should not be used as the sole source of
information about the member’s medical history. Information is believed to be accurate as of the production date; however, it is
subject to change. For more information about Aetna plans, refer to www.aetna.com.
www.aetna.com
©2014 Aetna Inc.
14.03.254.1-AZ B (7/14)

Arizona 2-100 Plan Guide

Transcription

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