How to get the Power of Ready on your side Your Benefits

Transcription

Your Benefits
Quick Start Guide
How to get the Power of Ready
on your side
Enroll in the Aetna insurance plans offered through PDS Technical Services today
Unexpected stuff happens to all of us. That’s why you need to be ready with insurance options from Aetna Voluntary Plans.
This is your opportunity to sign up for benefits. So take a few minutes to find out about your options now!
Please note, these plans provide supplemental benefits and are not a substitute for comprehensive medical insurance.
Open enrollment begins on December 1 and
ends on December 31, 2013.
If you were just hired, you have 31 days
from the date you are hired to enroll.
Medical PPO
AETNA VOLUNTARY PLANS
BIN# 610502 RX
PDS TECHNICAL SERVICES
GROUP NUMBER: 801289
YOUR NAME:
FOR MEMBER SERVICES CALL 1-888-772-9682
PAYER NUMBER 57604 0039
Cut out your temporary member identification along the dotted line.
8012891SGE(11/13)
12.03.436.1 (7/13)
Aetna Fixed BenefitsSM Plan
Pays fixed cash benefits for specific medical services and
includes Aetna’s nationwide provider network to help you
save money. Let your doctors know if you want Aetna to send
benefit payments to them directly. Or, you may choose to
receive the benefit payment directly to use as you want or
need.
Start your benefits!
How do I enroll?
First, read your enrollment information. To enroll, follow the
instructions on your How to Enroll Guide.
If you have questions, please call 1-888-772-9682.
If you’re currently enrolled in the limited medical
benefits plan, your medical plan will end and not
continue. If you want to be enrolled in the new Aetna
Fixed Benefits Plan, you must enroll now. Your old
medical plan enrollment will not roll over into the new
Fixed Benefits Plan.
Am I eligible to enroll?
The following two classes of employees are eligible to
participate: Class 1: All Core benefits eligible employees
during their 90-day Core Medical waiting period; and Class 2:
All Non-Core benefits eligible employees. If you are an
eligible employee, you can also enroll your eligible
dependents. Your eligible dependents are your lawful spouse
and your children from birth until age 26, through any age if
handicapped and unable to earn a living, or until they can no
longer be legally declared as dependents. Dependent age
and status requirements may vary by state.
How do I pay?
Payment is simple. Premium costs will be deducted from your
paycheck. If you miss a payment, you can pay directly and
keep your coverage active. There is a form in this kit to use
when sending in missed premium payments.
When does coverage begin?
Coverage is effective on the first day of the pay period
following the pay period in which a deduction occurs.
Signing up is easy!
First, read your enrollment information.
Call 1-888-772-9682
Between 8 a.m. and 6 p.m., Monday through
Friday.
Notice to Louisiana residents:
Your share of the payment for health care services may be
based on the agreement between your health plan and your
provider. Under certain circumstances, this agreement may
allow your provider to bill you for amounts up to the provider’s
regular billed charges.
If you choose coverage, please use this temporary
member ID until you get your plastic member ID card.
www.aetna.com/docfind/custom/avp
INSURED: The person listed on the card has been enrolled in a fixed indemnity
insurance plan sponsored by the employer. Available benefits are subject to
exclusions and limitations. This card does not guarantee coverage. For verification
of coverage, filing a claim or for questions other than the discount programs,
contact us at the number printed on the front of this card or mail us at the address
below.
EMERGENCY: Call 911 or go to the nearest emergency facility.
For AETNA VISION DISCOUNTS call 1-800-793-8616.
For LASIK call 1-800-422-6600.
For CONTACTS DIRECT call 1-800-391-5367.
Claims incurred in Louisiana will be paid within 30 days of receipt of a correctly
completed uniform claim form.
Strategic Resource Company
P.O. Box 14079
Lexington, KY 40512-4079
Insurance plans are underwritten by Aetna Life Insurance Company (Aetna). This material is for information only. Providers are
independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide
care or guarantee access to health services. Insurance plans contain exclusions and limitations. Information is believed to be
accurate as of the production date; however, it is subject to change. See the limitations and
exclusions document included in this kit for the Aetna insurance plans offered by your
employer.
Policy forms issued include: GR-9/GR-9N, GR-23, GR-29/GR-29N, GR-96172
and/or GR-96173.
©2013 Aetna Inc.
8012891SGE(11/13)
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Aetna Fixed
BenefitsSM Plan
Supplemental benefits you can use
toward deductibles, coinsurance or
everyday expenses
The Aetna Fixed Benefits Plan pays fixed cash
payments for specific covered services. You
can use these insurance benefits to help pay
some of the cost of doctor visits, hospital
stays, prescriptions or the everyday
expenses that arise when you have to get
medical care.
You choose how you want to spend the
payment. Payments can be made directly
to you or your health care provider. And if
you have a health insurance plan with a big
deductible, the Aetna Fixed Benefits Plan can
help you meet it.
More great reasons to buy this plan
with cash benefits to help
you pay your bills
57.03.348.1 A (7/13)
•Enrollment guaranteed — No pre-existing
condition limits, no doctor exam required
and you can’t be turned down during open
enrollment.
•Aetna network — See any licensed health
care provider, or save money by seeing a
provider in Aetna’s network.
•Easy to use — The plan pays regardless of
any other insurance coverage you may have.
If offered by your plan sponsor, the cost of
the plan may be deducted right from your
paycheck, so you won’t have a separate bill
to pay.
•Affordable — Group rates that are typically
less per week than the average cost of a
couple’s night out at the movies. See your
enrollment information for the cost of your
specific plan.
Please keep in mind
Membership has its perks!
The Aetna Fixed Benefits Plan provides limited coverage and is not a
substitute for regular health insurance. It is meant to complement other
health insurance coverage you may have. It’s also important to know that
the plan:
•When you buy this plan, you also receive
discounts on fitness, vision, hearing,
weight management, oral health and
other benefits!
•Our DocFind® online directory helps
you locate in-network doctors or
medical specialists in your area.
•Pays fixed dollar amounts per day for different kinds of medical services
regardless of how much you have to pay for them, with limits on the number
of benefits the plan will pay per year.
•Does not pay the full cost of medical care. You are responsible for making
sure your doctor gets paid. If you see a provider in Aetna’s network, the
amount you owe the provider is reduced because Aetna has already
negotiated a discount.
•Does not satisfy the Affordable Care Act’s requirement for most Americans
to have Minimum Essential Coverage beginning January 1, 2014, or face a
tax penalty. See www.healthcare.gov for more information.
•May invalidate the pretax status of any tax-deferred health savings account
that you have. If you or your spouse have a health savings account, please
consult your tax adviser before you enroll.
Exclusions and limitations
This plan does not cover all health care expenses and has 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, though your plan
may contain exceptions to this list based on state mandates or the plan design
purchased.
For more information, visit
www.aetna.com/docfind/custom/avp/
or call 1-888-772-9682.
Enroll today
Exclusions include:
•All medical or hospital services not specifically covered in, or which are
limited or excluded in, the plan documents
•Cosmetic surgery, including breast reduction
•Custodial care
•Experimental and investigational procedures
•Infertility services, including, but not limited to, artificial insemination and
advanced reproductive technologies, donor egg retrieval and reversal of
sterilization
•Non-medically necessary services or supplies
Follow the instructions provided
in your enrollment materials.
No benefit is paid for or in conjunction with the following stays or visits or
services:
•Those received outside the United States
•Those for education or job training, whether or not given in a facility that
also provides medical or psychiatric treatment
The Aetna Fixed Benefits Plan is underwritten by Aetna Life Insurance Company (Aetna).
This material is for information only. Providers are independent contractors and are not agents of Aetna. Provider participation may
change without notice. Aetna does not provide care or guarantee access to health services. Discount programs provide access to
discounted prices and are NOT insured benefits. The member is responsible for the full cost of the discounted services. Information is
believed to be accurate as of the production date; however, it is subject to change.
Policy forms issued include: GR-23, GR-96172 and/or GR-96173.
©2013 Aetna Inc.
57.03.348.1 A (7/13)
PDS Technical Services
801289
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BENEFITS SUMMARY
Aetna Voluntary Plans
Plan design and benefits insured by Aetna Life Insurance Company (Aetna).
Unless otherwise indicated, all benefits and limitations are per covered person.
Inside this Benefits Summary:
• Fixed Benefits Plan
IMPORTANT INFORMATION ABOUT THE BENEFITS YOU ARE BEING OFFERED: The Aetna
Fixed Benefits Plan is a hospital confinement indemnity plan with other fixed indemnity
benefits. This plan provides LIMITED BENEFITS. Benefits provided are supplemental and are not
intended to cover all medical expenses. This plan pays you fixed dollar amounts regardless of the
amount that the provider charges. You are responsible for making sure the provider's bills get paid.
These benefits are paid in addition to any other health coverage you may have. This disclosure
provides a very brief description of the important features of the benefits being considered. It is not
an insurance contract and only the actual policy provisions will control. THIS PLAN DOES NOT
COUNT AS MINIMUM ESSENTIAL COVERAGE UNDER THE AFFORDABLE CARE ACT.
If you are eligible for Medicare now or will be in the next 12 months: this prescription drug benefit is NOT
creditable coverage under Medicare Part D.
Aetna will pay benefits only for services provided while coverage is in force, and only for medically necessary, covered
services. These benefits may be modified where necessary to meet state mandated benefit requirements.
You can lower your medical expenses by seeing a participating provider in the Aetna Open Choice® PPO network.
To locate a participating provider, call toll-free 1-888-772-9682 or visit www.aetna.com/docfind/custom/avp
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Benefits Summary
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This policy does not meet Massachusetts Minimum Creditable Coverage standards.
This plan does not count as Minimum Essential Coverage under the Affordable Care Act.
Fixed Benefits Plan: Option 1
Inpatient Hospital Stay -- daily benefit
(Includes maternity)
Plan pays per day in a private or semi-private room
Plan pays per day in Intensive Care Unit (ICU)
Maximum number of stays per coverage year
Inpatient Hospital Stay - lump-sum benefit
Plan pays per initial day of an inpatient stay
Maximum number of days per coverage year
Inpatient surgical procedure
Plan pays per day on which a surgical procedure is performed
Accident - additional benefit
Plan pays per initial day of treatment for an accident
Emergency room
Plan pays per day on which an emergency room visit occurs
Outpatient surgical procedure
Outpatient doctors' office visits
Includes doctors' service in the office, home, walk-in clinic, and urgent care clinic.
Plan pays per day on which doctors' services are provided
Outpatient laboratory and x-ray services
Plan pays per day on which lab or x-ray services are provided
Prescription drugs, equipment and supplies
Plan pays per day on which a prescription drug, equipment or supply is obtained
$650
$1,300
2 stays
$900
2 days
$550
2 days
$400
2 days
$375
2 days
$550
2 days
$80
7 days
$110
3 days
$55
12 days
To use your prescription benefit:
A) Present your Aetna identification (ID) card to the pharmacist.
B) Participating pharmacies will apply a discount.
C) You pay the amount charged by the pharmacy.
D) Submit a medical claim form to SRC to receive your fixed benefit payment.
To find a participating pharmacy, call toll-free 1-888-772-9682 or visit www.aetna.com/docfind/custom/avp.
Services to prevent illness are covered under the applicable benefit (Outpatient doctors' office visits or Outpatient laboratory
and x-ray services) listed in this Benefit Summary, the same as services to treat illness.
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This policy does not meet Massachusetts Minimum Creditable Coverage standards.
This plan does not count as Minimum Essential Coverage under the Affordable Care Act.
Fixed Benefits Plan: Option 2
Inpatient Hospital Stay -- daily benefit
Plan pays per day in a private or semi-private room
Plan pays per day in Intensive Care Unit (ICU)
Maximum number of stays per coverage year
Inpatient Hospital Stay - lump-sum benefit
Plan pays per initial day of an inpatient stay
Inpatient surgical procedure
Accident - additional benefit
Plan pays per initial day of treatment for an accident
Emergency room
Plan pays per day on which an emergency room visit occurs
Outpatient surgical procedure
Outpatient doctors' office visits
Includes doctors' service in the office, home, walk-in clinic, and urgent care clinic.
Plan pays per day on which doctors' services are provided
Outpatient laboratory and x-ray services
Plan pays per day on which lab or x-ray services are provided
Prescription drugs, equipment and supplies
Plan pays per day on which a prescription drug, equipment or supply is obtained
$750
$1,500
2 stays
$1,100
2 days
$675
2 days
$400
2 days
$475
2 days
$675
2 days
$90
7 days
$130
3 days
$65
12 days
To use your prescription benefit:
A) Present your Aetna identification (ID) card to the pharmacist.
B) Participating pharmacies will apply a discount.
C) You pay the amount charged by the pharmacy.
D) Submit a medical claim form to SRC to receive your fixed benefit payment.
To find a participating pharmacy, call toll-free 1-888-772-9682 or visit www.aetna.com/docfind/custom/avp.
Services to prevent illness are covered under the applicable benefit (Outpatient doctors' office visits or Outpatient laboratory
and x-ray services) listed in this Benefit Summary, the same as services to treat illness.
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When you enroll in the Fixed Benefits Plan, you also receive:
Vision discounts
Our vision discounts use the nationwide EyeMed Vision Care Network of vision care providers to offer you and your family
discounts on eye glasses, contact lenses, nonprescription sunglasses, contact lens solutions and other eye care
accessories. Plus, you can receive discounts on eye exams and LASIK eye surgery. For exams and eyewear call 1-800793-8616. For contacts call 1-800-391-5367. For LASIK customer service call 1-800-422-6600. You can also locate a
local provider by visiting www.aetna.com/docfind/custom/avp. This discount arrangement may not be available to
Illinois residents.
Discount offers provide access to discounted services and are not part of an insured plan or policy.
Prescription drug discount program
The prescription drug discount program gives you and your family access to over 65,000 retail pharmacies nationwide. You
can also use our Aetna Rx Home Delivery® service; a fast, easy way to fill the prescriptions you take regularly. To locate a
participating pharmacy, call 1-888-772-9682 or visit www.aetna.com/docfind/custom/avp.
Discount programs provide access to discounted prices and are not insured benefits.
Informed Health® Line
Aetna's Informed Health® Line gives you and your family access to registered nurses 24 hours a day, 7 days a week. This
toll-free line connects you to a team of nurses experienced in providing information on a variety of health topics. Informed
Health Line nurses use the Healthwise® Knowledgebase to provide information about health issues, medical procedures
and treatment options, and help you and your family communicate more effectively with your doctors. You can also choose
to listen to certain health topics of interest through Aetna's new audio health library, which is available in English and
Spanish. Contact Aetna's Informed Health Line at 1-800-556-1555.
Aetna Resources For Living
Aetna Resources For Living helps you and your family manage stress and balance work and life. Resources related to
emotional support, childcare, and legal and financial guidance are available by telephone and online.
Services also include consultation, information, education and referral services in connection with:
• parenting
• adoption
• grandparent as parent
• childcare and summer care
• temporary back-up care
• special needs
• high-risk adolescents
• adult care and elder care
• mental health
• academic services
• home improvement
• pet care
• consumer information
• legal services
• financial counseling
• child safety information
• pre-natal information
These services are convenient and confidential, available 24 hours a day, 7 days a week by calling 1-800-599-7158 or
visiting www.mylifevalues.com. Log in with username MY123EAP and password MY123EAP.
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Fixed Benefits Plan Exclusions and Limitations
This plan has exclusions and limitations. Refer to the actual policy and booklet certificate to determine which 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 may contain exceptions to this list based on state mandates or the plan design purchased.
• All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents.
• Cosmetic surgery, including breast reduction.
• Custodial care.
• Experimental and investigational procedures.
• Infertility services, including donor egg retrieval, artificial insemination and advanced reproductive technologies, and
reversal of sterilization.
• Nonmedically necessary services or supplies.
No benefit is paid for or in connection with the following stays or visits or services:
• Those received outside the United States
• Those for education, special education or job training, whether or not given in a facility that also provides medical or
psychiatric treatment.
Terms defined
An Inpatient Hospital Stay (or "Stay") is a period during which you are admitted as an inpatient; and are confined in a
hospital, non-hospital residential facility, hospice facility, skilled nursing facility, or rehabilitation facility; and are charged for
room, board, and general nursing services. A Stay does not include time in the hospital because of custodial or personal
needs that do not require medical skills or training. A Stay specifically excludes time in the hospital for observation or in the
emergency room unless this leads to an Inpatient Stay.
A Negotiated Charge is the maximum amount that a preferred provider has agreed to charge for a covered visit, service,
or supply. After your plan limits have been reached, the provider may require that you pay the full charge rather than the
negotiated charge.
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Questions and answers about the Fixed Benefits Plan
The Fixed Benefits Plan is a fixed indemnity plan. How does a fixed indemnity plan work?
Fixed indemnity plans have no copays, deductibles, or coinsurance. A fixed indemnity plan pays a fixed amount per day or
other period, with limits on the number and types of services. Once you have used up your number of services, the plan
will no longer pay for that kind of service. Payments under the Fixed Benefits Plan can be used for any purpose you
choose. Because the plan pays a fixed amount, you may owe the provider more than the plan pays. If you choose a
preferred (in network) provider, then you may pay less, because the provider may accept payment for the negotiated
charge. Before you enroll in the plan, please read the benefits chart in the previous pages carefully to understand what this
plan will pay.
How does this fixed indemnity plan differ from a traditional comprehensive medical plan?
The Fixed Benefits Plan is intended to supplement, not substitute for, comprehensive medical coverage. Unlike most
major medical plans, this plan does not have catastrophic coverage or a limit on your out-of-pocket expenses. This means
that you may have large out-of-pocket costs if you have a serious or chronic medical condition. Because comprehensive
medical plans provide more coverage, they cost more. They typically satisfy the Affordable Care Act's mandate to
maintain Minimum Essential Coverage, but the Fixed Benefits Plan does not.
How does this fixed indemnity plan differ from a "mini-med" limited benefits plan?
If you were previously enrolled in a "mini-med" insurance plan, it is important to understand how a fixed indemnity plan is
different. A "mini-med" limited benefits plan pays a percentage of the charge (coinsurance) up to a maximum amount, and
may have limits on the number of services. A fixed indemnity plan pays a fixed amount per service regardless of the
amount of the charge, with limits on the number of some services. A "mini-med" plan may have copays and deductibles.
This fixed indemnity plan has no copays, deductibles, or coinsurance.
Does this fixed indemnity plan provide creditable coverage or COBRA continuation coverage?
Unlike a traditional health plan or an Aetna "mini-med" limited benefits plan, this fixed indemnity plan does not provide
creditable coverage under HIPAA and does not offer COBRA continuation coverage.
What will I pay up front when I go to a healthcare provider?
A provider may require that you pay all charges in advance, and it would be up to you to submit a claim for benefits under
the plan. Remember that you are responsible for making sure the provider's bill gets paid, even when the fixed benefit is
less than provider's charges.
What if I don’t understand something I’ve read here, or have more questions?
Please call us. We want you to understand these benefits before you decide to enroll. You may reach one of our
Customer Service representatives Monday through Friday, 8 a.m. to 6 p.m., by calling toll free 1-888-772-9682. We’re here
to answer questions before and after you enroll.
NOTICE TO TEXAS EMPLOYERS: THIS IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. THE
EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM BY PURCHASING
THIS POLICY, AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH
WOULD OTHERWISE ACCRUE UNDER THE WORKERS' COMPENSATION LAWS. THE EMPLOYER MUST COMPLY
WITH THE WORKERS' COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED
NOTIFICATIONS THAT MUST BE FILED AND POSTED.
ATTENTION MASSACHUSETTS RESIDENTS: As of January 1, 2009, the Massachusetts Health Care Reform Law
requires that Massachusetts residents, eighteen (18) years of age and older, must have health coverage that meets the
Minimum Creditable Coverage standards set by the Commonwealth Health Insurance Connector, unless waived from the
health insurance requirement based on affordability or individual hardship. For more information call the Connector at 1-877MA-ENROLL (1-877-623-6765) or visit the Connector website (www.mahealthconnector.org). THIS POLICY, ALONE,
DOES NOT MEET MINIMUM CREDITABLE COVERAGE STANDARDS. If you have questions about this notice, you may
contact the Division of Insurance by calling 617-521-7794 or visiting its website at www.mass.gov/doi.
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ATTENTION MISSOURI RESIDENTS: An optional rider for elective abortion has not been purchased by the group
contract holder pursuant to VAMS section 376.805. An enrollee who is a member of a group health plan with coverage for
elective abortions has the right to exclude and not pay for coverage for elective abortions if such coverage is contrary to his
or her moral, ethical or religious beliefs. Your plan sponsor does not include coverage for elective abortions.
This material is for information only and is not an offer or invitation to contract. Insurance plans contain exclusions and
limitations. Providers are independent contractors and are not agents of Aetna. Provider participation may change without
notice. Aetna does not provide care or guarantee access to health services. Not all health services are covered. See plan
documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and
availability may vary by location. 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. Discount programs provide access to discounted prices and are not insured benefits. Information is believed
to be accurate as of the production date; however, it is subject to change.
Policy forms issued include GR-9/GR-9N, GR-29/GR-29N, GR96172, and GR96173.
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Benefits Summary
Page 7
How to enroll
Read the materials in this enrollment kit and ask questions. If you or your family need to know more, or don’t completely understand
something, please call us toll free at 1-888-772-9682 or visit www.aetna.com/src. We’re here to answer questions before and after
you enroll.
Fill out your Enrollment/Change Request form. Then follow the instructions below to enroll online or by telephone, using the
information you wrote on the form. You do not need to give this form to your employer. If you are currently enrolled, you must reenroll if you wish to continue your coverage.
To enroll online:
A
Go to www.aetna.com/src.
B
Click on Log In, which will take you to the account access page.
C
Select Log In from the menu. Enter the user name and password.
User name: 801289
Password: 4559
D
Choose Enrollment from the panel on the left. Then follow the online instructions.
E
When complete, print a copy of the Confirmation page for your records. Your Confirmation Number is proof of successful
enrollment. Do not hand anything in to your employer.
To enroll by telephone:
A
Circle the number that matches the level of coverage you want.
Fixed Benefits Plan
You may enroll in only one medical option.
Coverage is not available if you live and work in
New Hampshire.
No coverage ............................................ 0
Option 1
Yourself only ........................................... 1
Yourself plus one.................................... 2
Yourself and family ................................ 3
Option 2
Yourself only ........................................... 4
Yourself plus one.................................... 5
Yourself and family ................................ 6
B
Write down the number you circled above.
This is the Benefit Code you will need when you call.
______
Fixed Benefits Plan
C
Next, call 1-800-977-6974 to enroll. Follow the instructions you hear on the phone. Your access code is 4559.
D
Listen for your Confirmation Number at the end of your call. Write it here: _________________________________________
The number is proof of successful enrollment. If you enroll your dependent(s), please stay on the phone to give your dependent
information to a Customer Service representative, Monday through Friday, 8 a.m. to 6 p.m. If enrolling outside of these times,
please call again later to give your information.
E
Keep your completed Enrollment/Change Request form and this enrollment guide for your records. Do not hand anything in to
your employer.
12.03.432.1 PDSTechnic (11/13)
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How to make changes
You may make changes to your enrollment at any time before the end of your enrollment period by following the enrollment
instructions on the front of this guide.
If your enrollment period is over, you will need a Qualifying Life Event (QLE) to make changes. You must make your changes within
30 days of the QLE.
For a list of QLEs, please see the back of your Enrollment/Change Request form, ask your employer or call 1-888-772-9682.
Make changes by filling out an Enrollment/Change Request form.
Then follow the instructions below to make changes, online or by telephone, using the information you wrote on the form. You do
not need to give this form to your employer.
To make changes online:
A
Go to www.aetna.com/src.
B
Click on Log In, which will take you to the account access page.
C
Select Log In from the menu. Enter the user name and password.
User name: 801289
Password: 4559
D
Choose Enrollment from the panel on the left. Then follow the online instructions to make changes.
E
After you have made your changes, print a copy of the Confirmation page for your records. Your Confirmation Number is proof
that your changes are successful. Do not hand anything in to your employer.
To make changes by telephone:
A
Call 1-800-977-6974 to make changes. Follow the instructions you hear on the phone. Your access code is 4559.
B
Listen for your Confirmation Number at the end of your call. Write it here: _________________________________________
Your changes have not been made until you get a Confirmation Number. If you enroll your dependent(s), please stay on the phone
to give your dependent information to a Customer Service representative, Monday through Friday, 8 a.m. to 6 p.m. If enrolling
outside of these times, please call again later to give your information.
C
Keep your completed Enrollment/Change Request form and this guide for your records. Do not hand anything in to your
employer.
Insurance plans are underwritten by Aetna Life Insurance Company (Aetna) and administered by Aetna or Strategic
Resource Company (SRC), an Aetna company. Information is believed to be accurate as of the production date;
however, it is subject to change. Policy forms issued include GR-9/GR-9N, GR-29/GR-29N, GR96172, and GR96173.
12.03.432.1 PDSTechnic (11/13)
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a
801289
(formerly Aetna Affordable Health Choices®)
Enrollment/Change Request
Insurance plans are underwritten by Aetna Life Insurance Company (Aetna) and administered
by Aetna or Strategic Resource Company (SRC), an Aetna company.
Instructions: Read and fill out the Enrollment/Change Request (all pages).
You must re-enroll in coverage.
INFORMATION ABOUT YOU Complete all information.
Print your name (first, middle initial, last)
Home address
Home phone
Social Security Number
Apartment number
Work phone
City
Email address
Date of birth (MM/DD/YYYY)
State
Sex
(
)
(
)
ACTION YOU WANT TO TAKE Check the box next to the action you want to take.
 Male
 Female
Zip code
Primary language spoken (Idioma principal)
I am not currently enrolled and I want to…
 Enroll in the coverage choices selected below.
 Decline this opportunity to participate.
I am currently enrolled and I want to…
 Make changes to my current coverage choices (add, increase, drop, decrease) as selected below.
All of my other coverage choices will remain the same as previously elected.
(If outside of an open enrollment, see “Making Changes Outside of an Open Enrollment.”)
 Update my personal and/or my dependent information.
 Drop all of my current coverage choices.
Your payroll deductions will be taken before taxes are taken.
YOUR COVERAGE CHOICES Check () the box for the level of coverage you want.
Coverage type
Coverage level
Fixed Benefits Plan
You may enroll in one medical
option only.
 No Fixed Benefits Plan
Option 1
 Yourself only........................................................................................................................................................................ $
 Yourself plus one................................................................................................................................................................. $
 Yourself and family.............................................................................................................................................................. $
Option 2
 Yourself only........................................................................................................................................................................ $
 Yourself plus one................................................................................................................................................................. $
 Yourself and family.............................................................................................................................................................. $
Weekly cost
21.06
46.81
67.40
25.76
57.38
82.68
YOUR AUTHORIZATION You must sign and date this Enrollment/Change Request for all new enrollments or coverage changes.
I represent that all information supplied in this Enrollment/Change Request is true and complete to the best of my knowledge and/or belief. I have read and agree to the
Conditions of Enrollment on the reverse side of this Enrollment/Change Request.
Your signature
Today’s date (MM/DD/YYYY)
Do you have a disability which affects your ability to communicate or read?  Yes  No
If “Yes,” please indicate the nature of your disability. ____________________________
EMPLOYER GROUP INFORMATION This section is to be completed by your employer.
Employee ID
Hire date (MM/DD/YYYY)
Pay type
Location or site code
Authorized signature
AFBP
12.08.303.1-TX
This Enrollment/Change Request is not proof of coverage.
Total deduction ($)
Effective date (MM/DD/YYYY)
Title
Today’s date (MM/DD/YYYY)
801289 / PDSTechnic
DE - 11/21/2013
INFORMATION ABOUT YOU Repeat your name and Social Security number here.
Print your name (first, middle initial, last)
INFORMATION ABOUT YOUR DEPENDENTS List the dependents for whom you are adding/changing/removing coverage.
If you have more dependents, write down their information on a separate sheet and attach it to this Enrollment/Change Request.
 Add
Print dependent’s name (first, middle initial, last)
 Change
 Remove
Sex
Date of birth
 Male /  Female
Relationship:
 Spouse
 Child
 Other (Specify): ______________________________________________
Address (if different than yours)
 Add
 Change
 Remove
City
Sex
State
Zip code
Date of birth
Relationship:
 Spouse
 Child
 Other (Specify): ______________________________________________
 Add
 Change
 Remove
City
Sex
State
Zip code
Date of birth
Relationship:
 Spouse
 Child
 Other (Specify): ______________________________________________
City
State
Zip code
MAKING CHANGES OUTSIDE OF AN OPEN ENROLLMENT Please read below to see if you are able to make changes to your coverage.
If your deductions are taken before taxes are taken out of your pay, you can change your coverage during
the plan year only if you have a Qualifying Life Event (QLE). QLEs fall under one of these two
categories:
Loss of Other Coverage (LOC): If you previously declined health coverage because you or your
dependents were already covered under another health plan and you or your dependents have lost that
other coverage, you may be able to enroll yourself and your dependents. If you had a recent LOC, go to
the list on the right and check the box next to your LOC and supply the date of the LOC.
Family Status Change (FSC): Whether you are currently enrolled or previously declined coverage, you
may be able to add or increase, drop or decrease coverage when you experience certain FSC events. If
you had a recent FSC, go to the list on the right and check the box next to your FSC and supply the date
of the FSC.
Loss of Other Coverage (LOC):
 Divorce, legal separation or death
 Termination of employment of a dependent
 Reduction of a dependent’s hours
 Termination of your or your dependents’ COBRA rights
 Loss of employer’s contribution to spouse’s coverage
 Dependent child losing eligibility as a dependent
 Other loss of coverage
Family Status Change (FSC):
 Divorce, legal separation or death
 Marriage
 Birth or adoption of a dependent
 Other
Date of LOC or FSC (mm/dd/yyyy)
AFBP
12.08.303.1-TX
801289 / PDSTechnic
DE - 11/21/2013
CONDITIONS OF ENROLLMENT Applicant acknowledgments and agreements
On behalf of myself and the dependents listed on this Enrollment/Change Request, I agree to or with the following:
1. I acknowledge that by enrolling in an Aetna plan coverage is underwritten by Aetna Life Insurance Company (referred to as "Aetna") 151 Farmington Avenue,
Hartford, CT 06156 and administered by Aetna or Strategic Resource Company (SRC, an Aetna company), 221 Dawson Road, Columbia, SC 29223.
2. I authorize deductions from my earnings for any contributions required for coverage and I agree to make any necessary payments as required for coverage.
3. I understand and agree that this Enrollment/Change Request may be transmitted to Aetna or its agent by my employer or its agent. I authorize any physician, other
healthcare professional, hospital or any other healthcare organization ("Providers") to give Aetna or its agent information concerning the medical history, services or
treatment provided to anyone listed on this Enrollment/Change Request, including those involving mental health, substance abuse and HIV/AIDS. I further authorize
Aetna to use such information and to disclose such information to affiliates, providers, payors, other insurers, third party administrators, vendors, consultants and
governmental authorities with jurisdiction when necessary for my care or treatment, payment for services, the operation of my health plan, or to conduct related
activities. I have discussed the terms of this authorization with my spouse and competent adult dependents and I have obtained their consent to those terms. I
understand that this authorization is provided under state law and that it is not an "authorization" within the meaning of the federal Health Insurance Portability and
Accountability Act. This authorization will remain valid for the term of the coverage and so long thereafter as allowed by law. I understand that I am entitled to
receive a copy of this authorization upon request and that a photocopy is as valid as the original.
4. The plan documents will determine the rights and responsibilities of member(s) and will govern in the event they conflict with any benefits comparison, summary or
other description of the plan.
5. I understand and agree that with the exception of Aetna Rx Home Delivery®, all participating providers and vendors are independent contractors and are neither
agents nor employees of Aetna. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed and
provider network composition is subject to change. Notice of the change shall be provided in accordance with applicable state law.
6. Misrepresentation: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance
or statement of claim containing any intentional misrepresentation of material fact or conceals, for the purpose of misleading, information concerning any fact material
thereto may commit a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties.
Attention Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance
or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits
a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Attention Rhode Island Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
AFBP
12.08.303.1-TX
801289 / PDSTechnic
DE - 11/21/2013
Aetna Plans
Missed Premium Payment Coupon
Aetna Life Insurance Company
Company name
Group number
Today’s date (mm/dd/yyyy)
Member name (last, first, middle initial)
Member daytime telephone number
Member Social Security number
Payment will be applied to the oldest gap in coverage within the last 45 days from the
postmark on your mailed payment. To find out what gaps in coverage you may have, please
call us toll free at 1-888-772-9682.
_______________________
X
Number of pay periods missed
$ ___________________________ =
Amount of deduction per pay period
$
________________________
Full premium payment due
Instructions: Make a copy of this page. Complete the
payment coupon. Cut along the dotted line. Mail
coupon with your full amount, made payable to
SRC/Aetna, to:
SRC Missed Premiums
P.O. Box 534739
Atlanta, GA 30353-4739
What if I miss a payroll deduction?
Your coverage will not begin until you have your first payroll deduction. Each payroll deduction pays for coverage for one payroll period. If you miss a
payroll deduction after your coverage begins, you will not have coverage during the time that payroll deduction would cover, unless you pay the full
missed premium directly to SRC.
Will my insurance be canceled if I don’t make up a missed premium?
Once your coverage has begun, it will not be canceled because you do not make up a missed premium. However, no claims will be paid for losses or
covered expenses that occur during the period for which premium is unpaid.
How do I pay my missed premium?
To pay by personal check, cashier’s check, or money order, make payable to SRC/Aetna and send with a completed copy of the coupon above to: SRC
Missed Premiums, P.O. Box 534739, Atlanta, GA 30353-4739. You can get additional payment coupons from www.aetna.com/src, or by calling
1-888-772-9682.
Can I pick which missed premiums I wish to pay?
No. Your missed premium payment will always be applied to the oldest gap in coverage within the last 45 days (from the postmark on your mailed
payment). You cannot choose to cover a later gap in coverage if you have an earlier gap within the past 45 days from the date your payment is
postmarked. To find out what gaps in coverage you may have, please call toll free 1-888-772-9682, Monday through Friday, 8 a.m. to 6 p.m.
How long do I have to pay a missed premium?
You may pay for a gap in coverage that is up to 45 days old, from the date your payment is postmarked.
Can I pay just a part of a missed premium?
No. You must pay the full premium deduction that was missed in your paycheck, for all coverage you have. We cannot accept partial payments.
If I become ineligible or my employment ends, can I continue coverage with missed premium payments?
No. If your coverage terminates, you may not continue coverage by paying missed premiums.
Insurance plans are underwritten by Aetna Life Insurance Company (Aetna) and administered by Aetna or Strategic
Resource Company (SRC), an Aetna company. Information is believed to be accurate as of the production date; however, it is
subject to change. Policy forms issued include GR-9/GR-9N, GR-29/GR-29N, GR96172, and GR96173.
12.03.386.1 A (06/13)
a
Important Disclosure Information
Aetna Affordable Health Choices® Indemnity Plans
Plan of Benefits
■
Your plan of benefits will be determined by your plan
sponsor and underwritten by the Aetna Life Insurance
Company, 151 Farmington Avenue, Hartford, Connecticut,
06156. The benefits and main points of the Group Policy
for persons covered under your plan of benefits will be set
forth in the Booklet-Certificate which will be provided to
you at a later date.
■
After-Hours Care
You may call your doctor's office 24 hours a day, 7 days a
week if you have medical questions or concerns. You may
also consider visiting participating Urgent Care facilities.
You are responsible for any copayments, coinsurance and
deductibles for covered services. These obligations are paid
directly to the provider or facility at the time the service is
rendered. Copayment, coinsurance and deductible
amounts are listed in your benefits summary and plan
documents.
Behavioral Health Provider Safety Data
Available
For information regarding our Behavioral Health provider
network safety data, please go to www.aetna.com and
review the quality and patient safety links posted:
www.aetna.com/docfind/quality.html#jcaho. You may
select the quality checks link for details regarding our
providers' safety reports.
Advance Directives
An advance directive is a legal document that states your
wishes for medical care. It can help doctors and family
members determine your medical treatment if, for some
reason, you can't make decisions about it yourself.
Claims Payment for Nonparticipating
Providers and Use of Claims Software
There are three types of advance directives:
■
■
If your plan includes coverage for out-of-network services,
and you obtain coverage under this portion of your plan,
you should be aware that Aetna generally determines
payment for an out-of-network provider by referring to (i)
commercially available data reflecting the customary
amount paid to most providers for a given service in that
geographic area or (ii) by accessing other contractual
arrangements. If such data is not commercially available,
our determination may be based upon our own data or
other sources. Aetna may also use computer software
(including ClaimCheck®) and other tools to take into
account factors such as the complexity, amount of time
needed and manner of billing. You may be responsible for
any charges Aetna determines are not covered under your
plan.
Living will - spells out the type and extent of care you
want to receive.
Durable power of attorney - appoints someone you
trust to make medical decisions for you.
Do-not-resuscitate order - states that you don't want
to be given CPR if your heart stops or if you stop
breathing.
You can create an advance directive in several ways:
■
■
Get an advance medical directive form from a health
care professional. Certain laws require health care
facilities that receive Medicare and Medicaid funds to
ask all patients at the time they are admitted if they
have an advance directive. You don't need an
advance directive to receive care. But we are required
by law to give you the chance to create one.
Ask for an advance directive form at state or local
offices on aging, bar associations, legal service
programs, or your local health department.
www.aetna.com
04.28.302.1-SRC C (9-08)
Create an advance directive using computer software
designed for this purpose.
Advanced Directives and Do Not Resuscitate Orders. American
Academy of Family Physicians, March 2005.
(Available at http://familydoctor.org/003.xml?printxml)
Cost Sharing
■
Work with a lawyer to write an advance directive.
1
Technology Review
Clinical Policy Bulletins
Aetna reviews new medical technologies, behavioral health
procedures, pharmaceuticals and devices to determine
which one should be covered by our plans. And we even
look at new uses for existing technologies to see if they
have potential. To review these innovations, we may:
Aetna's CPBs describe Aetna's policy determinations of
whether certain services or supplies are medically necessary
or experimental or investigational, based upon a review of
currently available clinical information.
■
■
■
■
Study medical research and scientific evidence on the
safety and effectiveness of medical technologies.
Clinical determinations in connection with individual
coverage decisions are made on a case-by case basis
consistent with applicable policies.
Consider position statements and clinical practice
guidelines from medical and government groups,
including the federal Agency for Health care
Research and Quality.
Aetna's CPBs do not constitute medical advice. Treating
providers are solely responsible for medical advice and for
your treatment. You should discuss any CPB related to your
coverage or condition with your treating provider.
Seek input from relevant specialists and experts in
the technology.
While Aetna's CPBs are developed to assist in
administering plan benefits, they do not constitute a
description of plan benefits. Each benefit plan defines
which services are covered, which are excluded, and which
are subject to dollar caps or other limits. You and your
providers will need to consult the benefit plan to
determine if there are any exclusions or other benefit
limitations applicable to this service or supply.
Determine whether the technologies are
experimental or investigational.
You can find out more on new tests and treatments in our
Clinical Policy Bulletins. You can find the bulletins at
www.aetna.com, under the "Members and Consumers"
menu.
CPBs are regularly updated and are therefore subject to
change. Aetna's CPBs are available online at
www.aetna.com.
Medically Necessary
"Medically necessary" means that the service or supply is
provided by a physician or other health care provider
exercising prudent clinical judgment for the purpose of
preventing, evaluating, diagnosing or treating an illness,
injury or disease or its symptoms, and that provision of the
service or supply is:
■
■
■
■
Filing a Complaint or Appeal
Aetna is committed to addressing your coverage issues,
complaints and problems. If you have a coverage issue or
other problem, call Member Services at the toll free
number on your ID card If Member Services is unable to
resolve your issue to your satisfaction, it will be forwarded
to the appropriate department for handling.
In accordance with generally accepted standards of
medical practice;
Clinically appropriate in accordance with generally
accepted standards of medical practice in terms of type,
frequency, extent, site and duration , and considered
effective for the illness, injury or disease;
If you are dissatisfied with the outcome of your initial
contact, you may file an appeal. Your appeal will be
decided in accordance with the procedures applicable to
your plan and applicable state law. Refer to your plan
documents for further details regarding your plan's appeal
procedure.
Not primarily for the convenience of you, or for the
physician or other health care provider; and
Not more costly than an alternative service or sequence
of services at least as likely to produce equivalent
therapeutic or diagnostic results as to the diagnosis or
treatment of the illness, injury or disease.
About Coverage Decisions
Sometimes we receive claims for services that may not be
covered by your health benefits plan or that aren't in line
with the terms of your plan. It can be confusing - even to
your doctors. Our job is to make coverage decisions based
on your specific benefits plan.
For these purposes "generally accepted standards of
medical practice" means standards that are based on
credible scientific evidence published in peer-reviewed
medical literature generally recognized by the relevant
medical community, or otherwise consistent with physician
specialty society recommendations and the views of
physicians practicing in relevant clinical areas and any other
relevant factors.
If a claim is denied, we'll send you a letter to let you know.
If you don't agree you can file an appeal. To file an appeal,
follow the directions in the letter that explains that your
claim was denied. Our appeals decisions will be based on
your plan provisions and any state and federal laws or
regulations that apply to your plan. You can learn more
about the appeal procedures for your plan from your plan
documents.
2
External Review
Interpreter/Hearing Impaired
Aetna established an external review process to give you
the opportunity of requesting an objective and timely
independent review of certain coverage denials. Once the
applicable appeal process has been exhausted, you may
request an external review of the decision if the coverage
denial, for which you would be financially responsible,
involves more than $500, and is based on lack of medical
necessity or on the experimental or investigational nature
of the proposed service or supply. Standards may vary by
state, if a state-mandated external review process exists
and applies to your plan.
When you require assistance from an Aetna representative,
call us during regular business hours at the number on
your ID card. Our representatives can:
■
Answer benefits questions
■
Find care outside your area
■
Advise you on how to file complaints and appeals
■
■
Connect you to behavioral health services (if included
in your plan)
Find specific health information
Multilingual hotline - 1-888-982-3862
(140 languages are available.
You must ask for an interpreter.)
TDD 1-800-628-3323 (hearing impaired only)
An Independent Review Organization (IRO) will assign the
case to a physician reviewer with appropriate expertise in
the area in question. After all necessary information is
submitted, an external review generally will be decided
within 30 calendar days of the request.
Quality Management Programs
Expedited reviews are available when a your physician
certifies that a delay in service would jeopardize your
health. Once the review is complete, the plan will abide by
the decision of the external reviewer. The cost for the
review will be borne by Aetna (except where state law
requires you to pay a filing fee as part of the state
mandated program).
Call Aetna to learn about the specific quality efforts we
have under way in your local area. Ask Member Services
for the phone number of your regional Quality
Management office. If you would like information about
Aetna Behavioral Health's Quality Management Program,
ask Member Services for the phone number of your Care
Management Center Quality Management office.
Certain states mandate external review of additional
benefit or service issues; some may require a filing fee. In
addition, certain states mandate the use of their own
external review process for medical necessity and
experimental/ investigational coverage decisions. For
further details regarding your plan's appeal process and
the availability of an external review process, call the
Member Services toll-free number listed on your ID card.
You may obtain an external review request form from
Member Services. You also may call your state insurance
or health department or consult their website for
additional information regarding state mandated external
review procedures.
Privacy Notice
Aetna considers personal information to be confidential
and has policies and procedures in place to protect it
against unlawful use and disclosure. By "personal
information," we mean information that relates to your
physical or mental health or condition, the provision of
health care to you, or payment for the provision of health
care to you. Personal information does not include publicly
available information or information that is available or
reported in a summarized or aggregate fashion but does
not identify you.
When necessary or appropriate for your care or treatment,
the operation of our health plans, or other related
activities, we use personal information internally, share it
with our affiliates, and disclose it to health care providers
(doctors, dentists, pharmacies, hospitals and other
caregivers), payors (health care provider organizations,
employers who sponsor self-funded health plans or who
share responsibility for the payment of benefits, and others
who may be financially responsible for payment for the
services or benefits you receive under your plan), other
insurers, third party administrators, vendors, consultants,
government authorities, and their respective agents. These
parties are required to keep personal information
confidential as provided by applicable law. Participating
network providers are also required to give you access to
Member Rights & Responsibilities
You have the right to receive a copy of our Member
Rights and Responsibilities Statement. This information
is available to you online at
www.aetna.com/about/MemberRights/. You can also
obtain a print copy by contacting Member Services at the
number on your ID card.
Member Services
To request additional information regarding benefits,
copayments or other charges, or how to file a claim,
complaint or appeal, or if you have any other questions,
you can contact member Services at the toll-free number
on your ID card.
www.aetna.com
3
your medical records within a reasonable amount of time
after you make a request.
Some of the ways in which personal information is used
include claims payment; utilization review and
management; medical necessity reviews; coordination of
care and benefits; preventive health, early detection, and
disease and case management; quality assessment and
improvement activities; auditing and anti-fraud activities;
performance measurement and outcomes assessment;
health claims analysis and reporting; health services
research; data and information systems management;
compliance with legal and regulatory requirements;
formulary management; litigation proceedings; transfer of
policies or contracts to and from other insurers, HMOs and
third party administrators; underwriting activities; and due
diligence activities in connection with the purchase or sale
of some or all of our business. We consider these activities
key for the operation of our health plans. To the extent
permitted by law, we use and disclose personal
information as provided above without your consent.
However, we recognize that you may not want to receive
unsolicited marketing materials unrelated to your health
benefits. We do not disclose personal information for these
marketing purposes unless you consent. We also have
policies addressing circumstances in which you are unable
to give consent.
To obtain a hard copy of our Notice of Privacy Practices,
which describes in greater detail our practices concerning
use and disclosure of personal information, please write to
Strategic Resource Company (SRC), Post Office Box 14079,
Lexington, KY 40512-4079. You can also visit our Internet
site at www.aetna.com/docfind/custom/aahc/. You can
link directly to the Notice of Privacy Practices by Plan Type,
by selecting the "Privacy Notices" link at the bottom of the
page, and selecting the link that corresponds to you
specific plan.
4
Other Disclosures
Louisiana
Aetna will not in any way use the results of genetic testing
to discriminate against applicants or enrollees.
Michigan
Intractable Pain Coverage
Aetna provides benefits for the evaluation and treatment
of intractable pain when it is determined to be medically
necessary and otherwise eligible by Aetna. Intractable pain
means "a pain state in which the cause of the pain cannot
be removed or otherwise treated and which, in the
generally accepted practice of allopathic or osteopathic
medicine, no relief of the cause of the pain or cure of the
cause of the pain is possible or none has been found after
reasonable efforts, including, but not limited to, evaluation
by the attending physician and by one or more other
physicians specializing in the treatment of the area, system,
or organ of the body perceived as the source of the pain."
To obtain this and further information on the health plan,
you may call Member Services at 1-888-772-9682.
www.aetna.com
5
Health Insurance Portability and
Accountability Act
Note: The following information is provided to inform you of certain provisions contained in
the Group Health Plan, and related procedures that may be utilized by you in accordance with
Federal law.
Special Enrollment Rights
Request for Certificate of Creditable
Coverage
If you are declining enrollment for yourself or your
dependents (including your spouse) because of other
health insurance or group health plan coverage, you may
be able to enroll yourself and your dependents in this plan
if you or your dependents lose eligibility for that other
coverage (or if the employer stops contributing towards
your or your dependents' other coverage). However, you
must request enrollment within 31 days after your or your
dependents' other coverage ends (or after the employer
stops contributing toward the other coverage). In addition,
if you have a new dependent as a result of marriage, birth,
adoption or placement for adoption, you may be able to
enroll yourself and your dependents. However, you must
request enrollment within 31 days after the marriage,
birth, adoption or placement for adoption. To request
special enrollment or obtain more information, contact
your benefits administrator.
If you are a member of an insured plan sponsor or a
member of a self insured plan sponsor who have
contracted with us to provide Certificates of Prior Health
Coverage, you have the option to request a certificate. This
applies to you if you are a terminated member, or are a
member who is currently active but who would like a
certificate to verify your status. As a terminated member,
you can request a certificate for up to 24 months following
the date of your termination. As an active member can
request a certificate at any time. To request a Certificate of
Prior Health Coverage, please contact Member Services at
the telephone number listed on your ID card.
If you need this material translated into another language, please call Member Services at 1-888-772-9682.
Si usted necesita este documento en otro idioma, por favor llame a Servicios al Miembro al 1-888-772-9682.
Health benefits and health insurance plans are underwritten by Aetna Life Insurance Company and administered by Strategic Resource Company.
6

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